Provider Demographics
NPI:1962557439
Name:LYDA, GLENN B (CPO)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:B
Last Name:LYDA
Suffix:
Gender:M
Credentials:CPO
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Mailing Address - Street 1:3305 16TH AVE SE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CONOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28613-9213
Mailing Address - Country:US
Mailing Address - Phone:828-994-4808
Mailing Address - Fax:828-994-4809
Practice Address - Street 1:3305 16TH AVE SE
Practice Address - Street 2:SUITE 101
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-9213
Practice Address - Country:US
Practice Address - Phone:828-994-4808
Practice Address - Fax:828-994-4809
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2016-06-07
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795183Medicaid