Provider Demographics
NPI:1295721843
Name:GLENN, BRYAN C (DC)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:C
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 1:535 LINCOLN WAY W
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-1800
Mailing Address - Country:US
Mailing Address - Phone:574-255-1716
Mailing Address - Fax:
Practice Address - Street 1:535 LINCOLN WAY W
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1800
Practice Address - Country:US
Practice Address - Phone:574-255-1716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001703A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200119230AMedicaid
IN000000202168OtherANTHEM
IN200119230AMedicaid