Provider Demographics
NPI:1831268143
Name:REELY, GLEN AQUILLA (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:AQUILLA
Last Name:REELY
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S NORTH ST
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973
Mailing Address - Country:US
Mailing Address - Phone:302-629-0278
Mailing Address - Fax:302-629-0278
Practice Address - Street 1:110 S NORTH ST
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973
Practice Address - Country:US
Practice Address - Phone:302-629-0278
Practice Address - Fax:302-629-0278
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0268700001Medicare ID - Type Unspecified