Healthcare Provider Details

I. General information

NPI: 1538696745
Provider Name (Legal Business Name): GLENN ERHARDT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 SUNSET DR
ONTARIO OR
97914-3121
US

IV. Provider business mailing address

702 SUNSET DR
ONTARIO OR
97914-3121
US

V. Phone/Fax

Practice location:
  • Phone: 541-889-9167
  • Fax: 541-889-7873
Mailing address:
  • Phone: 541-889-9167
  • Fax: 541-889-7873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: