Provider Demographics
NPI:1780757682
Name:ROBINSON, GLENN KELLY (DC)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:KELLY
Last Name:ROBINSON
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 1:2807 HWY 84 EAST
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828
Mailing Address - Country:US
Mailing Address - Phone:229-377-9064
Mailing Address - Fax:229-377-3926
Practice Address - Street 1:1473 CRINE BLVD
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-1430
Practice Address - Country:US
Practice Address - Phone:229-377-9818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005262111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000851188AMedicaid
GA202I353299Medicare PIN
GAU66803Medicare UPIN