Provider Demographics
NPI:1992935720
Name:GLENN, RICHARD LEE (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEE
Last Name:GLENN
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 1:401 N UNION AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3948
Mailing Address - Country:US
Mailing Address - Phone:575-623-2900
Mailing Address - Fax:
Practice Address - Street 1:100 E LINDA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6654
Practice Address - Country:US
Practice Address - Phone:575-623-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11204111N00000X
NM1909111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor