=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487324802
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HANS COLGLAZIER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2021
-----------------------------------------------------
Last Update Date | 09/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3040 NE 190TH ST APT 305
-----------------------------------------------------
City | AVENTURA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33180-3149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-728-9527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3040 NE 190TH ST APT 305
-----------------------------------------------------
City | AVENTURA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33180-3149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-728-9527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA96101
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------