Provider Demographics
NPI:1659408169
Name:GROSSMAN, GLENN RICHARD (LAC, AC, CH NCCAOM)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:RICHARD
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:LAC, AC, CH NCCAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6639 CENTURION DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-8276
Mailing Address - Country:US
Mailing Address - Phone:517-323-3858
Mailing Address - Fax:
Practice Address - Street 1:6639 CENTURION DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-8276
Practice Address - Country:US
Practice Address - Phone:517-323-3858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5153171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist