Provider Demographics
NPI:1538266101
Name:WILLIAMS, GLENN R (DC, LAC)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 351475
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-9175
Mailing Address - Country:US
Mailing Address - Phone:310-474-2221
Mailing Address - Fax:310-446-5323
Practice Address - Street 1:10801 NATIONAL BLVD
Practice Address - Street 2:#607
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-4139
Practice Address - Country:US
Practice Address - Phone:310-474-2221
Practice Address - Fax:310-446-5323
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC12099111N00000X
CAAC 1590171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC12099Medicare ID - Type Unspecified