Basic Information
| Provider Information | |||||||||
| NPI: | 1467869743 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLENDALE HEALTHCARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6320 W UNION HILLS DR | ||||||||
| Address2: | STE 1400B | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853081096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028895833 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6320 W UNION HILLS DR | ||||||||
| Address2: | STE 1400B | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853081096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028895833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2014 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | TRUJILLO | ||||||||
| AuthorizedOfficialFirstName: | MARTHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 6028895833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 363LF0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.