Healthcare Provider Details

I. General information

NPI: 1164969135
Provider Name (Legal Business Name): GLEN DEPKE BS, ND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 QUAIL ST SUITE 106
NEWPORT BEACH CA
92660-2729
US

IV. Provider business mailing address

1300 QUAIL ST SUITE 106
NEWPORT BEACH CA
92660-2729
US

V. Phone/Fax

Practice location:
  • Phone: 949-954-6226
  • Fax:
Mailing address:
  • Phone: 949-954-6226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: