Provider Demographics
NPI:1225001423
Name:GLENDALE OPHTHALMOLOGY ASC LP
Entity Type:Organization
Organization Name:GLENDALE OPHTHALMOLOGY ASC LP
Other - Org Name:GLENDALE EYE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:607 N CENTRAL AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1804
Mailing Address - Country:US
Mailing Address - Phone:818-956-1010
Mailing Address - Fax:818-543-6083
Practice Address - Street 1:607 N CENTRAL AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1804
Practice Address - Country:US
Practice Address - Phone:818-956-1010
Practice Address - Fax:818-543-6083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000717261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-C0001131Medicaid
CA=========OtherHEALTH NET FED. SERV.
CA05-C0001131Medicaid
CA490005402Medicare PIN