Healthcare Provider Details

I. General information

NPI: 1629784855
Provider Name (Legal Business Name): GLEN S COCHRANE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 01/31/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 EAST DESERT ROAD S 102
LAS VEGAS NV
89109
US

IV. Provider business mailing address

1090 EAST DESERT ROAD S 102
LAS VEGAS NV
89109
US

V. Phone/Fax

Practice location:
  • Phone: 702-333-1995
  • Fax: 702-333-0602
Mailing address:
  • Phone: 702-333-1995
  • Fax: 702-333-0602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: GLEN S COCHRANE
Title or Position: OWNER
Credential: DC
Phone: 702-333-1995