Basic Information
| Provider Information | |||||||||
| NPI: | 1821116393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLOVER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39833 90TH ST W | ||||||||
| Address2: | |||||||||
| City: | LEONA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935517404 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 43423 DIVISION ST STE 107 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935354640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617262850 | ||||||||
| FaxNumber: | 6617262854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 10/04/2010 | ||||||||
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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 | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 104100000X | 29163 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.