1073168340 NPI number — DR. CALVIN BENJAMIN GLIDDEN III PT, DPT, LAT, ATC

Table of content: DR. CALVIN BENJAMIN GLIDDEN III PT, DPT, LAT, ATC (NPI 1073168340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073168340 NPI number — DR. CALVIN BENJAMIN GLIDDEN III PT, DPT, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLIDDEN
Provider First Name:
CALVIN
Provider Middle Name:
BENJAMIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
PT, DPT, LAT, ATC
Provider Gender Code:
M

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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073168340
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
928 TIMBER RIDGE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLESON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76028-2509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-760-5420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 HERDNER RD UNIT C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87571-5362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-613-1093
Provider Business Practice Location Address Fax Number:
575-613-1093
Provider Enumeration Date:
08/05/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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