Provider Demographics
NPI:1164969135
Name:DEPKE, GLEN (BS, ND)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:DEPKE
Suffix:
Gender:M
Credentials:BS, ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 QUAIL ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2729
Mailing Address - Country:US
Mailing Address - Phone:949-954-6226
Mailing Address - Fax:
Practice Address - Street 1:1300 QUAIL ST
Practice Address - Street 2:SUITE 106
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2729
Practice Address - Country:US
Practice Address - Phone:949-954-6226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator