Healthcare Provider Details

I. General information

NPI: 1417021494
Provider Name (Legal Business Name): GLENN DODGE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 NW 1ST ST STE 1
ONTARIO OR
97914-2468
US

IV. Provider business mailing address

33648 APPLE VALLEY RD
PARMA ID
83660-6404
US

V. Phone/Fax

Practice location:
  • Phone: 541-889-4550
  • Fax: 541-889-4628
Mailing address:
  • Phone: 208-484-1498
  • Fax: 541-889-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3474
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: