Provider Demographics
NPI:1699728949
Name:MILLER, GLENN C (DC)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:C
Last Name:MILLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3637 LARCH AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-8448
Mailing Address - Country:US
Mailing Address - Phone:530-542-4778
Mailing Address - Fax:530-544-9112
Practice Address - Street 1:3637 LARCH AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-8448
Practice Address - Country:US
Practice Address - Phone:530-542-4778
Practice Address - Fax:530-544-9112
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0117810Medicare ID - Type Unspecified