Provider Demographics
NPI:1528310877
Name:GLASS, MATTHEW L (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:GLASS
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 1:1400 MARSH LANDING PKWY STE 107
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2492
Mailing Address - Country:US
Mailing Address - Phone:917-595-9061
Mailing Address - Fax:
Practice Address - Street 1:1400 MARSH LANDING PKWY STE 107
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-2492
Practice Address - Country:US
Practice Address - Phone:904-644-3472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012784-1111N00000X
FLCH13651111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor