Basic Information
| Provider Information | |||||||||
| NPI: | 1497077739 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLENDORA GRAND, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 W. ARROW HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917405413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263310781 | ||||||||
| FaxNumber: | 6263328835 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 W. ARROW HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917405413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263310781 | ||||||||
| FaxNumber: | 6263328835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2010 | ||||||||
| LastUpdateDate: | 03/25/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROLLINS | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6263310781 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 950000079 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 950000079 | 05 | CA | MEDICAID |