1396984423 NPI number — MARCIA J GLENN MD & ASSOCIATES DERMATOLOGY & LASER MED CTR INC

Table of content: (NPI 1396984423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396984423 NPI number — MARCIA J GLENN MD & ASSOCIATES DERMATOLOGY & LASER MED CTR INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARCIA J GLENN MD & ASSOCIATES DERMATOLOGY & LASER MED CTR INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1396984423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4644 LINCOLN BLVD STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARINA DEL REY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90292-6391
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-821-7658
Provider Business Mailing Address Fax Number:
310-821-1708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4644 LINCOLN BLVD STE 500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARINA DEL REY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90292-6391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-821-7658
Provider Business Practice Location Address Fax Number:
310-301-1783
Provider Enumeration Date:
02/12/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GLENN
Authorized Official First Name:
MARCIA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-821-7658

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  G63373 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207NP0225X , with the licence number: G63373 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)