| Organization Name: | COURTNEY GLENN DPM LLC |
| NPI Number: | 1306221106 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | COURTNEY GLENN (OWNER) |
| Mailing Address: | 1574 Friendship Rd # 200 Hoschton |
| State: | GA US |
| Postal Code: | 305484146 |
| Phone Number: | 7706485040 |
| Fax Number: | |
| NPI Enumeration Date: | 07/22/2015 |
| NPI Last Update Date: | 07/22/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP1100X |
| License Number: | POD001277 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Podiatric |
| Taxonomy Definition: | |