Provider Demographics
NPI:1598316259
Name:ROLDAN, GLENN SCOTT ADRIANO
Entity Type:Individual
Prefix:
First Name:GLENN SCOTT
Middle Name:ADRIANO
Last Name:ROLDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 LEGACY CT
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CA
Mailing Address - Zip Code:95368-9758
Mailing Address - Country:US
Mailing Address - Phone:925-876-5326
Mailing Address - Fax:
Practice Address - Street 1:4220 LEGACY CT
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CA
Practice Address - Zip Code:95368-9758
Practice Address - Country:US
Practice Address - Phone:925-876-5326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA450246ZE0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG