Provider Demographics
NPI:1386911741
Name:HAKE, GLEN BRUCE JR (DC)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:BRUCE
Last Name:HAKE
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:3100 MAIN ST
Mailing Address - Street 2:#358
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75226-1535
Mailing Address - Country:US
Mailing Address - Phone:214-815-7484
Mailing Address - Fax:972-266-7383
Practice Address - Street 1:1710 SMALL ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-6041
Practice Address - Country:US
Practice Address - Phone:972-266-9123
Practice Address - Fax:972-266-7383
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX6160111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor