Provider Demographics
NPI:1457762536
Name:DR JOSEPH GLANDON LLC
Entity Type:Organization
Organization Name:DR JOSEPH GLANDON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:GLANDON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-292-3112
Mailing Address - Street 1:17034 173RD LN SE
Mailing Address - Street 2:
Mailing Address - City:RAINIER
Mailing Address - State:WA
Mailing Address - Zip Code:98576-9411
Mailing Address - Country:US
Mailing Address - Phone:360-292-3112
Mailing Address - Fax:
Practice Address - Street 1:1401 GALAXY DR NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-4746
Practice Address - Country:US
Practice Address - Phone:360-456-7867
Practice Address - Fax:360-456-7869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1287152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2062503Medicaid