Basic Information
| Provider Information | |||||||||
| NPI: | 1356388961 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLENN MEDICAL CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1133 W SYCAMORE ST | ||||||||
| Address2: | |||||||||
| City: | WILLOWS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959882601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309341800 | ||||||||
| FaxNumber: | 5309341818 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 W SYCAMORE ST | ||||||||
| Address2: | |||||||||
| City: | WILLOWS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959882601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309341800 | ||||||||
| FaxNumber: | 5309341818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2092876308 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 23000001 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHM13981H | 05 | CA | MEDICAID |