Healthcare Provider Details

I. General information

NPI: 1255360855
Provider Name (Legal Business Name): GLEN MICHAEL PALMISANO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 LANDSHARK BLVD
DAYTONA BEACH FL
32124-3727
US

IV. Provider business mailing address

633 LANDSHARK BLVD
DAYTONA BEACH FL
32124-3727
US

V. Phone/Fax

Practice location:
  • Phone: 860-585-9797
  • Fax: 860-589-9002
Mailing address:
  • Phone: 860-751-8501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH5911
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number000681
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number000681
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number5711
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: