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General NPI Number Information
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NPI Number | 1821176124
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Entity Type | Organization
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Legal Business Name | GLENN F DEVRIES
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Dates
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Enumeration Date | 11/02/2006
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Last Update Date | 02/17/2009
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Provider Practice Location Address
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Address Line | 322 BROADWAY ST
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City | BERLIN
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State | WI
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Zip | 54923-1706
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Country | US
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Telephone | 920-361-3036
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Fax | 920-361-7317
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Provider Business Mailing Address
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Address Line | 322 BROADWAY ST
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City | BERLIN
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State | WI
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Zip | 54923-1706
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Country | US
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Telephone | 920-361-3036
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Fax | 920-361-7317
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Authorized Official
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Title or Position | OWNER
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Name | GLENN F DEVRIES
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Credential | DPM
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Telephone | 920-361-3036
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 467
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License Number State | WI
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