Provider Demographics
NPI:1962556456
Name:NYKWEST, GLEN IRVING (DC)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:IRVING
Last Name:NYKWEST
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 1:106 WASHINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10570
Mailing Address - Country:US
Mailing Address - Phone:914-273-5505
Mailing Address - Fax:914-273-6519
Practice Address - Street 1:106 WASHINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NY
Practice Address - Zip Code:10570
Practice Address - Country:US
Practice Address - Phone:914-273-5505
Practice Address - Fax:914-273-6519
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002303-1111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX13101Medicare ID - Type UnspecifiedMEDICARE