Provider Demographics
NPI:1508291022
Name:GLEN PARK AT MONROVIA
Entity Type:Organization
Organization Name:GLEN PARK AT MONROVIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TILLMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PINK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:818-242-9000
Mailing Address - Street 1:1220 MARIPOSA ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-3254
Mailing Address - Country:US
Mailing Address - Phone:818-242-9000
Mailing Address - Fax:
Practice Address - Street 1:110 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2435
Practice Address - Country:US
Practice Address - Phone:626-357-6818
Practice Address - Fax:626-305-5339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-04
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197802560310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility