Provider Demographics
NPI:1215934682
Name:GLAZE CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:GLAZE CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-843-5643
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:GILMER
Mailing Address - State:TX
Mailing Address - Zip Code:75644-0949
Mailing Address - Country:US
Mailing Address - Phone:903-843-5643
Mailing Address - Fax:903-843-4403
Practice Address - Street 1:1026 TITUS ST
Practice Address - Street 2:
Practice Address - City:GILMER
Practice Address - State:TX
Practice Address - Zip Code:75644-3514
Practice Address - Country:US
Practice Address - Phone:903-843-5643
Practice Address - Fax:903-843-4403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0017CC111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0017CCMedicare ID - Type Unspecified