Provider Demographics
NPI:1033592894
Name:GLU FACTORY, INC
Entity Type:Organization
Organization Name:GLU FACTORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:575-935-4458
Mailing Address - Street 1:1200 N THORNTON ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-5508
Mailing Address - Country:US
Mailing Address - Phone:575-935-4458
Mailing Address - Fax:
Practice Address - Street 1:1200 N THORNTON ST
Practice Address - Street 2:SUITE F
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5508
Practice Address - Country:US
Practice Address - Phone:575-935-4458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM6533578Medicaid