Healthcare Provider Details

I. General information

NPI: 1992783583
Provider Name (Legal Business Name): GLENN M STARK DC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 COMMONWEALTH BLVD E
MARTINSVILLE VA
24112-2014
US

IV. Provider business mailing address

425 COMMONWEALTH BLVD E
MARTINSVILLE VA
24112-2014
US

V. Phone/Fax

Practice location:
  • Phone: 276-632-2226
  • Fax: 276-632-2395
Mailing address:
  • Phone: 276-632-2226
  • Fax: 276-632-2395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104000930
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: