Provider Demographics
NPI:1881663524
Name:GLENN, CHARLES RAYMOND (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RAYMOND
Last Name:GLENN
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 1:2183 MARINER BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-3860
Mailing Address - Country:US
Mailing Address - Phone:352-686-2554
Mailing Address - Fax:352-686-3302
Practice Address - Street 1:2183 MARINER BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-3860
Practice Address - Country:US
Practice Address - Phone:352-686-2554
Practice Address - Fax:352-686-3302
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0001927111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH0001927OtherLICENSE NUMBER
FLT34497Medicare UPIN
FLCH0001927OtherLICENSE NUMBER