Healthcare Provider Details

I. General information

NPI: 1215840129
Provider Name (Legal Business Name): BRENT GLAZE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 LOKCHAPEE DR
MACON GA
31210-4214
US

IV. Provider business mailing address

616 LOKCHAPEE DR
MACON GA
31210-4214
US

V. Phone/Fax

Practice location:
  • Phone: 678-296-2806
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP008192
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: