Healthcare Provider Details

I. General information

NPI: 1508443805
Provider Name (Legal Business Name): GLENN FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 MAUI LANI PKWY
WAILUKU HI
96793-2416
US

IV. Provider business mailing address

85 MAUI LANI PKWY
WAILUKU HI
96793-2416
US

V. Phone/Fax

Practice location:
  • Phone: 330-904-9354
  • Fax:
Mailing address:
  • Phone: 808-244-5366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TRAVIS WAGNER GLENN
Title or Position: MEMBER
Credential: MD
Phone: 808-244-5366