Provider Demographics
NPI:1528050952
Name:WINNESTAFFER, GLENN M (DC, DIBCN)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:WINNESTAFFER
Suffix:
Gender:M
Credentials:DC, DIBCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 S HAMILTON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-3311
Mailing Address - Country:US
Mailing Address - Phone:614-471-5442
Mailing Address - Fax:614-471-5462
Practice Address - Street 1:358 S HAMILTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-3311
Practice Address - Country:US
Practice Address - Phone:614-471-5442
Practice Address - Fax:614-471-5462
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2080111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0957460Medicaid
OHU49134Medicare UPIN
OH0957460Medicaid