Provider Demographics
NPI:1477150787
Name:GLOM SUBSTANCE ABUSE PROGRAM
Entity Type:Organization
Organization Name:GLOM SUBSTANCE ABUSE PROGRAM
Other - Org Name:G.L.O.M. OUTPATIENT SERVICES INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAGDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-999-4119
Mailing Address - Street 1:3123 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-7595
Mailing Address - Country:US
Mailing Address - Phone:925-570-3282
Mailing Address - Fax:925-800-3102
Practice Address - Street 1:1020 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-4521
Practice Address - Country:US
Practice Address - Phone:925-570-3282
Practice Address - Fax:925-800-3102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC2630352OtherMEDI-CAL