Provider Demographics
NPI:1124704531
Name:VELASQUEZ, GLENN
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:VELASQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4223 LANDRIANO AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-4941
Mailing Address - Country:US
Mailing Address - Phone:408-745-9402
Mailing Address - Fax:702-357-8317
Practice Address - Street 1:4223 LANDRIANO AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-4941
Practice Address - Country:US
Practice Address - Phone:408-745-9402
Practice Address - Fax:702-357-8317
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant