Provider Demographics
NPI:1497369425
Name:GLORYLAND HEALTHCARE LLC
Entity Type:Organization
Organization Name:GLORYLAND HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:EZENTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-526-2468
Mailing Address - Street 1:17222 MERRY SONG CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2963
Mailing Address - Country:US
Mailing Address - Phone:513-526-2468
Mailing Address - Fax:
Practice Address - Street 1:17222 MERRY SONG CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-2963
Practice Address - Country:US
Practice Address - Phone:513-526-2468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)