Provider Demographics
NPI:1649223280
Name:RIDDLE, GLENN PAUL (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:PAUL
Last Name:RIDDLE
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 1:4617 MILE STRETCH DR
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34690-4330
Mailing Address - Country:US
Mailing Address - Phone:727-938-5322
Mailing Address - Fax:727-943-9546
Practice Address - Street 1:4617 MILE STRETCH DR
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34690-4330
Practice Address - Country:US
Practice Address - Phone:727-938-5322
Practice Address - Fax:727-943-9546
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0006712111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380417800Medicaid
FL22960Medicare ID - Type Unspecified
FL380417800Medicaid