Healthcare Provider Details

I. General information

NPI: 1316129919
Provider Name (Legal Business Name): LAURIE GLANZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 CHURCH ST
MOUNT CLEMENS MI
48043-2331
US

IV. Provider business mailing address

35 CHURCH ST
MOUNT CLEMENS MI
48043-2331
US

V. Phone/Fax

Practice location:
  • Phone: 586-463-1555
  • Fax: 586-463-7550
Mailing address:
  • Phone: 586-463-1555
  • Fax: 586-463-7550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberLG001020
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberLG001020
License Number StateMI

VIII. Authorized Official

Name: LAURIE BETH GLANZ
Title or Position: LAURIE B GLANZ DPM
Credential: DPM
Phone: 586-463-1555