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General NPI Number Information
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NPI Number | 1285701888
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Entity Type | Individual
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Provider Name | GLENN DAVID LEDERMAN D.C.
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Gender | Male
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Dates
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Enumeration Date | 11/29/2006
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Last Update Date | 11/03/2016
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Provider Practice Location Address
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Address Line | 18 TUTOR PL
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-3658
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Country | US
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Telephone | 732-570-5675
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6262
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-6262
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH7049
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | MC04697
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License Number State | NJ
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