Provider Demographics
NPI:1639129638
Name:GEADA, GLENN J (DC)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:J
Last Name:GEADA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:GLENN
Other - Middle Name:J
Other - Last Name:GEADA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 2818
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29721
Mailing Address - Country:US
Mailing Address - Phone:803-283-8442
Mailing Address - Fax:803-286-4604
Practice Address - Street 1:106-A WOODLAND DR.
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720
Practice Address - Country:US
Practice Address - Phone:803-283-8442
Practice Address - Fax:803-286-4604
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2158111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2158Medicaid
SCU72554Medicare UPIN