Healthcare Provider Details

I. General information

NPI: 1598455057
Provider Name (Legal Business Name): GLENNA REINHARDT LO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GLENNA KOZAREK

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 FRANCE AVE S STE 164
EDINA MN
55435-1802
US

IV. Provider business mailing address

6432 WILRYAN AVE
EDINA MN
55439-1446
US

V. Phone/Fax

Practice location:
  • Phone: 612-889-0973
  • Fax:
Mailing address:
  • Phone: 612-889-0973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number1048
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: