Provider Demographics
NPI:1184255820
Name:GLASS, ERIC B (LMT, MAT)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:B
Last Name:GLASS
Suffix:
Gender:M
Credentials:LMT, MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 13TH AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2628
Mailing Address - Country:US
Mailing Address - Phone:701-809-1179
Mailing Address - Fax:
Practice Address - Street 1:5257 27TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7780
Practice Address - Country:US
Practice Address - Phone:701-809-1179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1479225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist