Provider Demographics
NPI:1275859548
Name:GLENN K. TAKEI, M.D., INC.
Entity Type:Organization
Organization Name:GLENN K. TAKEI, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE FACILITATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-357-9931
Mailing Address - Street 1:931 BUENA VISTA ST
Mailing Address - Street 2:SUITE 505
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-1712
Mailing Address - Country:US
Mailing Address - Phone:626-357-9931
Mailing Address - Fax:626-359-0739
Practice Address - Street 1:931 BUENA VISTA ST
Practice Address - Street 2:SUITE 505
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-1712
Practice Address - Country:US
Practice Address - Phone:626-357-9931
Practice Address - Fax:626-359-0739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35093207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G350930Medicaid
CAA46210Medicare UPIN
CAG35093Medicare PIN