Healthcare Provider Details

I. General information

NPI: 1336868066
Provider Name (Legal Business Name): JUSTIN LEE GLANCY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUSTIN LEE GLANCY DPM

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

IV. Provider business mailing address

74000 COUNTRY CLUB DR
PALM DESERT CA
92260-1685
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 909-825-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberEL7061
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE6171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: