Provider Demographics
NPI:1346283017
Name:GLENN MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:GLENN MEDICAL CENTER, LLC
Other - Org Name:GLENN FAMILY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE/CFO
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-287-6308
Mailing Address - Street 1:1133 W SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:WILLOWS
Mailing Address - State:CA
Mailing Address - Zip Code:95988-2601
Mailing Address - Country:US
Mailing Address - Phone:530-934-1800
Mailing Address - Fax:530-934-1818
Practice Address - Street 1:130 N ENRIGHT AVE
Practice Address - Street 2:
Practice Address - City:WILLOWS
Practice Address - State:CA
Practice Address - Zip Code:95988-2716
Practice Address - Country:US
Practice Address - Phone:530-934-1800
Practice Address - Fax:530-934-1818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23000001261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM08572GMedicaid
CARHM08572GMedicaid