=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649322769
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLENN M EICHENAUER DOM AP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 01/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2145 S TAMIAMI TRL
-----------------------------------------------------
City | OSPREY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34229-9696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-926-4711
-----------------------------------------------------
Fax | 941-926-4711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2145 S TAMIAMI TRL
-----------------------------------------------------
City | OSPREY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34229-9696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-926-4711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP1658
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------