Provider Demographics
NPI:1386380186
Name:THOMAS, GLENN
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:THOMAS
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 1:12619 LERWICK PL
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838-5546
Mailing Address - Country:US
Mailing Address - Phone:804-350-1001
Mailing Address - Fax:510-323-8161
Practice Address - Street 1:12619 LERWICK PL
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23838-5546
Practice Address - Country:US
Practice Address - Phone:804-350-1001
Practice Address - Fax:510-323-8161
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT65437321343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)