Healthcare Provider Details

I. General information

NPI: 1073651725
Provider Name (Legal Business Name): DAVID MARK GLICK D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7329 BOULDER VIEW LN
RICHMOND VA
23225-4953
US

IV. Provider business mailing address

PO BOX 2597
CHESTERFIELD VA
23832-9115
US

V. Phone/Fax

Practice location:
  • Phone: 804-327-0084
  • Fax: 866-602-1146
Mailing address:
  • Phone: 804-327-0084
  • Fax: 866-602-1146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number0104000858
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License NumberF--0000526
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number38MC00446700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: