Healthcare Provider Details

I. General information

NPI: 1053505693
Provider Name (Legal Business Name): LARRY G GLASS RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 GREGORY LN
ERLANGER KY
41018-3817
US

IV. Provider business mailing address

3808 GREGORY LN
ERLANGER KY
41018-3817
US

V. Phone/Fax

Practice location:
  • Phone: 859-727-6330
  • Fax:
Mailing address:
  • Phone: 859-727-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License Number6093
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: