Basic Information
| Provider Information | |||||||||
| NPI: | 1639747710 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLASS | ||||||||
| FirstName: | RACCIYIA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1270 WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432063172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146499428 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4664 LARWELL DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432203621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144877805 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2021 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | OH | Y |
No ID Information.