Healthcare Provider Details

I. General information

NPI: 1588949325
Provider Name (Legal Business Name): RONALD EDGAR GLOETZNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 SHADE TREE LN
TIJERAS NM
87059-7637
US

IV. Provider business mailing address

30 SHADE TREE LN
TIJERAS NM
87059-7637
US

V. Phone/Fax

Practice location:
  • Phone: 505-281-9109
  • Fax:
Mailing address:
  • Phone: 505-281-9109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number352857
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: