Healthcare Provider Details

I. General information

NPI: 1538443213
Provider Name (Legal Business Name): GLENN M SALES RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W10485 COUNTY LINE RD
BUTTERNUT WI
54514-9041
US

IV. Provider business mailing address

W10485 COUNTY LINE RD
BUTTERNUT WI
54514-9041
US

V. Phone/Fax

Practice location:
  • Phone: 715-769-3361
  • Fax:
Mailing address:
  • Phone: 715-769-3361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number77373-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: