MEDICARE: JAMES EVAN GLINN JR. PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT20130	CA

General Provider Information

NPI Number	:	1417985797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES EVAN GLINN JR. PT

Provider Business Mailing Address
First Line	:	1106 WALNUT ST
Second Line	:	SUITE 110
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-2416
Country	:	US
Telephone Number	:	805-788-0805
Fax Number	:	805-788-0845

Provider Business Practice Location Address
First Line	:	805 AEROVISTA PL
Second Line	:	SUITE 104
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-7919
Country	:	US
Telephone Number	:	805-543-7771
Fax Number	:	805-543-7761

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	03/23/2021

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