Provider Demographics
NPI:1790368645
Name:MARICELLI, GLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:
Last Name:MARICELLI
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 1:2330 S HIGGINS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6923
Mailing Address - Country:US
Mailing Address - Phone:406-728-0222
Mailing Address - Fax:
Practice Address - Street 1:2330 S HIGGINS AVE STE 100
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6923
Practice Address - Country:US
Practice Address - Phone:406-728-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTCHI-CHI-LIC-6766111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor