Healthcare Provider Details

I. General information

NPI: 1679679971
Provider Name (Legal Business Name): GLAZA CHIROPRACTIC CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 NAUTICAL DR SUITE 204
LAKE WYLIE SC
29710-0016
US

IV. Provider business mailing address

548 NAUTICAL DR SUITE 204
LAKE WYLIE SC
29710-0016
US

V. Phone/Fax

Practice location:
  • Phone: 803-831-2345
  • Fax: 803-831-2007
Mailing address:
  • Phone: 803-831-2345
  • Fax: 803-831-2007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1193
License Number StateSC

VIII. Authorized Official

Name: DR. AL GERARD GLAZA
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 803-831-2345