Provider Demographics
NPI:1588949325
Name:GLOETZNER, RONALD EDGAR
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:EDGAR
Last Name:GLOETZNER
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 1:30 SHADE TREE LN
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-7637
Mailing Address - Country:US
Mailing Address - Phone:505-281-9109
Mailing Address - Fax:
Practice Address - Street 1:30 SHADE TREE LN
Practice Address - Street 2:
Practice Address - City:TIJERAS
Practice Address - State:NM
Practice Address - Zip Code:87059-7637
Practice Address - Country:US
Practice Address - Phone:505-281-9109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM352857171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications