Provider Demographics
NPI:1518330802
Name:PHOENIX, GLENN (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:PHOENIX
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1846 E FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4700
Mailing Address - Country:US
Mailing Address - Phone:704-864-0356
Mailing Address - Fax:704-868-0858
Practice Address - Street 1:1846 E FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4700
Practice Address - Country:US
Practice Address - Phone:704-864-0356
Practice Address - Fax:704-868-0858
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1134111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor