Provider Demographics
NPI:1932178142
Name:GLENN, GARLAND DWAIN II (DC)
Entity Type:Individual
Prefix:DR
First Name:GARLAND
Middle Name:DWAIN
Last Name:GLENN
Suffix:II
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11509 HEMINGWAY DR
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20194-1240
Mailing Address - Country:US
Mailing Address - Phone:703-303-8844
Mailing Address - Fax:
Practice Address - Street 1:11710 PLAZA AMERICA DR STE 2000
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-4743
Practice Address - Country:US
Practice Address - Phone:703-303-8844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9612111N00000X
VA0104557290111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC753118466OtherBLUE CROSS BLUE SHIELD #
SCT134740281Medicare UPIN