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General NPI Number Information
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NPI Number | 1770034860
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Entity Type | Individual
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Provider Name | GLENN GOTTNER
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Gender | Male
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Dates
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Enumeration Date | 10/24/2016
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Last Update Date | 10/24/2016
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Provider Practice Location Address
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Address Line | 5435 BULL VALLEY RD SUITE 118
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City | MCHENRY
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State | IL
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Zip | 60050-7434
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Country | US
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Telephone | 815-363-7007
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Fax |
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Provider Business Mailing Address
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Address Line | 3581 LAKEVIEW DR
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City | ALGONQUIN
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State | IL
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Zip | 60102-4815
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Country | US
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Telephone | 847-458-7660
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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 | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 198.000834
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License Number State | IL
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