Provider Demographics
NPI:1821107921
Name:GULAU, GLENN M (DC)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:GULAU
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 1:760 WHALERS WAY STE C100
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3373
Mailing Address - Country:US
Mailing Address - Phone:970-407-0000
Mailing Address - Fax:970-282-6927
Practice Address - Street 1:760 WHALERS WAY STE C100
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3373
Practice Address - Country:US
Practice Address - Phone:970-407-0000
Practice Address - Fax:970-282-6927
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4240111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU79163Medicare UPIN
COC48873Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER