Provider Demographics
NPI:1396740528
Name:GLISSON, JAMES RANDALL (DC)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RANDALL
Last Name:GLISSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:GLISSSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:910 MOUNT HOMER RD
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6258
Mailing Address - Country:US
Mailing Address - Phone:352-357-8615
Mailing Address - Fax:352-357-5873
Practice Address - Street 1:910 MOUNT HOMER RD
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6258
Practice Address - Country:US
Practice Address - Phone:352-357-8615
Practice Address - Fax:352-357-5873
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5282111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT85515Medicare UPIN
FL70853YMedicare PIN