Provider Demographics
NPI:1831430016
Name:MIRACLE, GLENN (PT)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:MIRACLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 E FIR AVE
Mailing Address - Street 2:STE. 102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3862
Mailing Address - Country:US
Mailing Address - Phone:559-322-1703
Mailing Address - Fax:559-322-1793
Practice Address - Street 1:1903 E FIR AVE
Practice Address - Street 2:STE. 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3862
Practice Address - Country:US
Practice Address - Phone:559-322-1703
Practice Address - Fax:559-322-1793
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA398812251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic