Basic Information
| Provider Information | |||||||||
| NPI: | 1750307229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HILDRETH | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RRT | ||||||||
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| Mailing Information | |||||||||
| Address1: | NEMOURS CHILDREN&APOS S CLINIC | ||||||||
| Address2: | P.O. BOX 409992 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303840001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043903610 | ||||||||
| FaxNumber: | 9042885890 | ||||||||
| Practice Location | |||||||||
| Address1: | 5153 N 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505054700 | ||||||||
| FaxNumber: | 8505054711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 227900000X | RT6634 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | 227800000X | RT6634 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Certified |
ID Information
| ID | Type | State | Issuer | Description | 886758500 | 05 | FL | MEDICAID |