1467875005 NPI number — GLEN CHARLES NOBLES JR. NP-C

Table of content: GLEN CHARLES NOBLES JR. NP-C (NPI 1467875005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467875005 NPI number — GLEN CHARLES NOBLES JR. NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOBLES
Provider First Name:
GLEN
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
NP-C
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:
1467875005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1338 SOUTH BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHIPLEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32428-1846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-638-6240
Provider Business Mailing Address Fax Number:
850-415-5010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1338 SOUTH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHIPLEY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32428-1846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-638-6240
Provider Business Practice Location Address Fax Number:
850-415-5010
Provider Enumeration Date:
02/03/2014

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: 363LF0000X , with the licence number:  ARNP 9320777 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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