Provider Demographics
NPI:1497875611
Name:TESSMAN, GLEN ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:ROBERT
Last Name:TESSMAN
Suffix:
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 1:201 N RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-4114
Mailing Address - Country:US
Mailing Address - Phone:817-641-9700
Mailing Address - Fax:817-641-8190
Practice Address - Street 1:201 N RIDGEWAY DR
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4114
Practice Address - Country:US
Practice Address - Phone:817-641-9700
Practice Address - Fax:817-641-8190
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9660111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00641259OtherRR MEDICARE
TXU97868Medicare UPIN
TX8F8073Medicare PIN
TX610161Medicare ID - Type Unspecified