=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861813511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLEN SIEGEL P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2013
-----------------------------------------------------
Last Update Date | 12/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7942 PINES BLVD
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-6908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-966-8770
-----------------------------------------------------
Fax | 954-367-1226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7942 PINES BLVD
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-6908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-966-8770
-----------------------------------------------------
Fax | 954-367-1226
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GLEN SIEGEL
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 954-966-8770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH0002753
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------