Provider Demographics
NPI:1770034860
Name:GOTTNER, GLENN
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:GOTTNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3581 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-4815
Mailing Address - Country:US
Mailing Address - Phone:847-458-7660
Mailing Address - Fax:
Practice Address - Street 1:5435 BULL VALLEY RD
Practice Address - Street 2:SUITE 118
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-7434
Practice Address - Country:US
Practice Address - Phone:815-363-7007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000834171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist