Provider Demographics
NPI:1801811005
Name:GLENN, KEVIN SCOTT (DC,DABCO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:SCOTT
Last Name:GLENN
Suffix:
Gender:M
Credentials:DC,DABCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23341 GOLDEN SPRINGS DR STE 202
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2054
Mailing Address - Country:US
Mailing Address - Phone:909-860-0148
Mailing Address - Fax:909-860-9348
Practice Address - Street 1:23341 GOLDEN SPRINGS DR STE 202
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2054
Practice Address - Country:US
Practice Address - Phone:909-860-0148
Practice Address - Fax:909-860-9348
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16390111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT18319Medicare UPIN