Provider Demographics
NPI:1902267693
Name:GLAZE, TOMMY
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:
Last Name:GLAZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9519 EAGLEWOOD GLEN TRL
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-6596
Mailing Address - Country:US
Mailing Address - Phone:832-245-4571
Mailing Address - Fax:832-664-9083
Practice Address - Street 1:9519 EAGLEWOOD GLEN TRL
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-6596
Practice Address - Country:US
Practice Address - Phone:832-245-4571
Practice Address - Fax:832-664-9083
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004010X096A1OtherCOMMUNITY HEALTH SERVICES