Basic Information
| Provider Information | |||||||||
| NPI: | 1619929759 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLENN MEDICAL CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GLENN MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1133 W. SYCAMORE STREET | ||||||||
| Address2: | |||||||||
| City: | WILLOWS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959882601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309341800 | ||||||||
| FaxNumber: | 5309341865 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 W. SYCAMORE STREET | ||||||||
| Address2: | |||||||||
| City: | WILLOWS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959882601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309341800 | ||||||||
| FaxNumber: | 5309341865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO/VP FINANCE | ||||||||
| 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 | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 282NC0060X | 23000001 | CA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | RHM13981H | 05 | CA | MEDICAID | RHM08572G | 05 | CA | MEDICAID | HSP30092J | 05 | CA | MEDICAID | HSP40092J | 05 | CA | MEDICAID |