Healthcare Provider Details

I. General information

NPI: 1194264770
Provider Name (Legal Business Name): GLENN EDUARD CHRISTIANE WUYTS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 SADLER WAY
FAIRBANKS AK
99701-3175
US

IV. Provider business mailing address

4232 LAKE TAHOE CIR
WEST PALM BEACH FL
33409-7875
US

V. Phone/Fax

Practice location:
  • Phone: 412-636-2127
  • Fax:
Mailing address:
  • Phone: 412-636-2127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040742
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: