Basic Information
| Provider Information | |||||||||
| NPI: | 1922135680 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST VALLEY GLENDORA HOSPITAL LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GLENDORA COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 E GUASTI RD FL 3 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917618655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092354400 | ||||||||
| FaxNumber: | 9092354419 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 W ROUTE 66 | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917406207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268526125 | ||||||||
| FaxNumber: | 6268525055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 06/21/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEATHER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9092354332 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 930000060 | CA | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | HSM30205I | 05 | CA | MEDICAID | ZZT30205I | 05 | CA | MEDICAID |