Provider Demographics
NPI:1497077739
Name:GLENDORA GRAND, INC.
Entity Type:Organization
Organization Name:GLENDORA GRAND, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:626-331-0781
Mailing Address - Street 1:805 W. ARROW HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-5413
Mailing Address - Country:US
Mailing Address - Phone:626-331-0781
Mailing Address - Fax:626-332-8835
Practice Address - Street 1:805 W. ARROW HIGHWAY
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-5413
Practice Address - Country:US
Practice Address - Phone:626-331-0781
Practice Address - Fax:626-332-8835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950000079314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA950000079Medicaid
CA056079Medicare Oscar/Certification