Provider Demographics
NPI:1093302291
Name:GLORYHOUSE ILP
Entity Type:Organization
Organization Name:GLORYHOUSE ILP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-614-8960
Mailing Address - Street 1:3173 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-2178
Mailing Address - Country:US
Mailing Address - Phone:225-778-7678
Mailing Address - Fax:
Practice Address - Street 1:3173 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-2178
Practice Address - Country:US
Practice Address - Phone:225-778-7678
Practice Address - Fax:225-341-6825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health