Provider Demographics
NPI:1639167752
Name:SCHAFFER, GLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:
Last Name:SCHAFFER
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 1:19150 ACORN RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-3657
Mailing Address - Country:US
Mailing Address - Phone:239-267-3133
Mailing Address - Fax:239-267-8032
Practice Address - Street 1:19150 ACORN RD
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-3657
Practice Address - Country:US
Practice Address - Phone:239-267-3133
Practice Address - Fax:239-267-8032
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0004195111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
350007311OtherRR MEDICARE
FL3806162-00Medicaid
440696OtherPCA
593466707OtherCAC
350007311OtherUHCRR MEDICARE
FL88957ZMedicare PIN
593466707OtherCAC