Provider Demographics
NPI:1124571526
Name:GLEN TERRA ASSISTED LIVING
Entity Type:Organization
Organization Name:GLEN TERRA ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RECORDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-291-9220
Mailing Address - Street 1:917 N LOUISE ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207-2084
Mailing Address - Country:US
Mailing Address - Phone:818-291-9220
Mailing Address - Fax:818-291-9856
Practice Address - Street 1:917 N LOUISE ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91207-2084
Practice Address - Country:US
Practice Address - Phone:818-291-9220
Practice Address - Fax:818-291-9856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197608367310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility