Provider Demographics
NPI:1912382300
Name:ROE, GLEN
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:ROE
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 1:1516 E 23RD ST S STE C
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-1601
Mailing Address - Country:US
Mailing Address - Phone:816-254-2700
Mailing Address - Fax:816-254-2703
Practice Address - Street 1:1516 E 23RD ST S STE C
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-1601
Practice Address - Country:US
Practice Address - Phone:816-254-2700
Practice Address - Fax:816-254-2703
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015001134237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015001134OtherHEARING DISPENSER LICENSE