Basic Information
| Provider Information | |||||||||
| NPI: | 1194817916 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLASS SEATING AND MOBILITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1687 N SHELBY OAKS DR | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381347421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013790096 | ||||||||
| FaxNumber: | 9013790018 | ||||||||
| Practice Location | |||||||||
| Address1: | 1687 N SHELBY OAKS DR | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381347421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013790096 | ||||||||
| FaxNumber: | 9013790018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | OWENS | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | GLASS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9013790096 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | ATS, ATP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 0000000805 | TN | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332B00000X | 06285/11.1 | MS | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BC3200X | 06285/11.1 | MS | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 332BC3200X | 0000000805 | TN | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 07089577 | 05 | MS | MEDICAID | 1454612 | 05 | TN | MEDICAID |