Provider Demographics
NPI:1619371341
Name:WIGGAN, GLENMORE (OTR/L)
Entity Type:Individual
Prefix:
First Name:GLENMORE
Middle Name:
Last Name:WIGGAN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 LURTING AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3712
Mailing Address - Country:US
Mailing Address - Phone:347-231-9516
Mailing Address - Fax:
Practice Address - Street 1:3322 LURTING AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-3712
Practice Address - Country:US
Practice Address - Phone:347-231-9516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015911-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility