Provider Demographics
NPI:1689887846
Name:MELLUSI, GLENN C (DC)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:C
Last Name:MELLUSI
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 1:238 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-1154
Mailing Address - Country:US
Mailing Address - Phone:908-531-4885
Mailing Address - Fax:
Practice Address - Street 1:185 MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018
Practice Address - Country:US
Practice Address - Phone:201-486-2883
Practice Address - Fax:862-520-1339
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00502400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ898970Medicare ID - Type Unspecified