Provider Demographics
NPI:1285900431
Name:GLEN R. LACINSKI, D.C A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:GLEN R. LACINSKI, D.C A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LACINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:520-881-0451
Mailing Address - Street 1:1135 N CRAYCROFT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4914
Mailing Address - Country:US
Mailing Address - Phone:520-881-0451
Mailing Address - Fax:
Practice Address - Street 1:1135 N CRAYCROFT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4914
Practice Address - Country:US
Practice Address - Phone:520-881-0451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-31
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5075111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty