Provider Demographics
NPI:1942055074
Name:ASHLOCK, GLEN
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:ASHLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-0189
Mailing Address - Country:US
Mailing Address - Phone:517-592-1974
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 189
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-0189
Practice Address - Country:US
Practice Address - Phone:517-592-1974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist