Provider Demographics
NPI:1649322769
Name:EICHENAUER, GLENN M (DOM AP)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:EICHENAUER
Suffix:
Gender:M
Credentials:DOM AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:OSPREY
Mailing Address - State:FL
Mailing Address - Zip Code:34229-9696
Mailing Address - Country:US
Mailing Address - Phone:941-926-4711
Mailing Address - Fax:
Practice Address - Street 1:2145 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:OSPREY
Practice Address - State:FL
Practice Address - Zip Code:34229-9696
Practice Address - Country:US
Practice Address - Phone:941-926-4711
Practice Address - Fax:941-926-4711
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1658171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAP1658OtherSTATE LICENSE #