Provider Demographics
NPI:1972552743
Name:MANCEAUX, GLENN D (PT, DC, CCSP)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:D
Last Name:MANCEAUX
Suffix:
Gender:M
Credentials:PT, DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6902 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-2455
Mailing Address - Country:US
Mailing Address - Phone:985-868-3136
Mailing Address - Fax:985-868-4040
Practice Address - Street 1:6902 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2455
Practice Address - Country:US
Practice Address - Phone:985-868-3136
Practice Address - Fax:985-868-4040
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA635111N00000X
LA00334225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAU20090Medicare UPIN
LA59462Medicare PIN
LA4C513Medicare PIN