Provider Demographics
NPI:1760569990
Name:GLASS, ROBIN IRVIN (DC, DACNB)
Entity Type:Individual
Prefix:DR
First Name:ROBIN
Middle Name:IRVIN
Last Name:GLASS
Suffix:
Gender:M
Credentials:DC, DACNB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 N VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-5620
Mailing Address - Country:US
Mailing Address - Phone:505-634-0714
Mailing Address - Fax:505-632-1111
Practice Address - Street 1:308 N 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-5305
Practice Address - Country:US
Practice Address - Phone:505-634-0714
Practice Address - Fax:505-632-1111
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM782111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM267-2780Medicare ID - Type Unspecified