Provider Demographics
NPI:1558332619
Name:CIANCIULLI, GLEN G (DC)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:G
Last Name:CIANCIULLI
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 1:422 ELMORA AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-1553
Mailing Address - Country:US
Mailing Address - Phone:908-289-6515
Mailing Address - Fax:908-576-0982
Practice Address - Street 1:422 ELMORA AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-1553
Practice Address - Country:US
Practice Address - Phone:908-289-6515
Practice Address - Fax:908-576-0982
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2012-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00441600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ046962P0KMedicare PIN
NJU84585Medicare UPIN