Provider Demographics
NPI:1942547062
Name:EZELL, GLENN R (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:EZELL
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 1:2201 1ST CAPITOL DR STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-5805
Mailing Address - Country:US
Mailing Address - Phone:636-485-6661
Mailing Address - Fax:
Practice Address - Street 1:2201 1ST CAPITOL DR STE 101
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-5805
Practice Address - Country:US
Practice Address - Phone:636-485-6661
Practice Address - Fax:636-916-0668
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013000467111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor