Healthcare Provider Details

I. General information

NPI: 1861502486
Provider Name (Legal Business Name): GLENN MICHAEL LOEBIG D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

754 WALKER RD
GREAT FALLS VA
22066-2654
US

IV. Provider business mailing address

754 WALKER RD
GREAT FALLS VA
22066-2654
US

V. Phone/Fax

Practice location:
  • Phone: 703-757-5817
  • Fax: 703-757-5478
Mailing address:
  • Phone: 703-757-5817
  • Fax: 703-757-5478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104001591
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: