MEDICARE: AL GLAZA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	1193	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306805916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AL GLAZA

Provider Business Mailing Address
First Line	:	110 GREEN MEADOW CT
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28056-7112
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	146 HIGHWAY 274
Second Line	:
City	:	LAKE WYLIE
State	:	SC
Zip	:	29710-6045
Country	:	US
Telephone Number	:	803-831-2345
Fax Number	:	803-831-2007

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	07/08/2007

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Directions to “ AL GLAZA ” Practice Location

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