Healthcare Provider Details

I. General information

NPI: 1346210036
Provider Name (Legal Business Name): MARK G GLEN RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5736 EAGLE CT
SAINT CLOUD MN
56303-4663
US

IV. Provider business mailing address

5736 EAGLE CT
SAINT CLOUD MN
56303-4663
US

V. Phone/Fax

Practice location:
  • Phone: 320-493-1472
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1948
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: