Provider Demographics
NPI:1861424475
Name:GLASS, TIMOTHY M (DC)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:M
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 1:2535 HUALAPAI MOUNTAIN RD.
Mailing Address - Street 2:SUITE C
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401
Mailing Address - Country:US
Mailing Address - Phone:928-692-8300
Mailing Address - Fax:928-692-1323
Practice Address - Street 1:2535 HUALAPAI MOUNTAIN RD.
Practice Address - Street 2:SUITE C
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401
Practice Address - Country:US
Practice Address - Phone:928-692-8300
Practice Address - Fax:928-692-1323
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5210111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ350038374OtherRAILROAD MEDICARE
AZAZ0243170OtherBLUE CROSS
AZ44-00109OtherUHC
AZ404963OtherAPIPA
AZU4-7723Medicare UPIN
AZZDC5210Medicare PIN
AZ44-00109OtherUHC
AZAZ0243170OtherBLUE CROSS