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General NPI Number Information
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NPI Number | 1861686503
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Entity Type | Organization
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Legal Business Name | GLAS CHIROPRACTIC S.C.
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Dates
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Enumeration Date | 09/05/2007
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Last Update Date | 06/25/2012
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Provider Practice Location Address
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Address Line | 1415 W RIVERVIEW DR
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City | EAST PEORIA
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State | IL
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Zip | 61611-9647
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Country | US
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Telephone | 309-453-7607
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Fax |
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Provider Business Mailing Address
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Address Line | 1415 W RIVERVIEW DR
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City | EAST PEORIA
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State | IL
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Zip | 61611-9647
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Country | US
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Telephone | 309-453-7607
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Fax |
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Authorized Official
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Title or Position | PRINCIPAL OFFICER
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Name | DR. BRET BYRON GLAS
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Credential | D.C.
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Telephone | 309-453-7607
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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 | 042619123
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License Number State | IL
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