Provider Demographics
NPI:1730947243
Name:THE GLOW STUDIO ACUPUNCTURE, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:THE GLOW STUDIO ACUPUNCTURE, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LORRIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:FISSENDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, MSTCM
Authorized Official - Phone:816-739-2457
Mailing Address - Street 1:624 CANYON RD
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4305
Mailing Address - Country:US
Mailing Address - Phone:816-739-2457
Mailing Address - Fax:
Practice Address - Street 1:1615 HILL RD STE G
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-4338
Practice Address - Country:US
Practice Address - Phone:415-761-1440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center