Provider Demographics
NPI:1194311654
Name:GLENN, RONNIE
Entity type:Individual
Prefix:
First Name:RONNIE
Middle Name:
Last Name:GLENN
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 1:6497 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-9195
Mailing Address - Country:US
Mailing Address - Phone:614-402-5194
Mailing Address - Fax:
Practice Address - Street 1:6497 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-9195
Practice Address - Country:US
Practice Address - Phone:614-402-5194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRT505487172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver