Provider Demographics
NPI:1518140920
Name:GLEN-PARK WEST RETIREMENT COMMUNITY, INC
Entity Type:Organization
Organization Name:GLEN-PARK WEST RETIREMENT COMMUNITY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TILLMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PINK JR
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:818-242-3972
Practice Address - Street 1:1220 MARIPOSA ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-3254
Practice Address - Country:US
Practice Address - Phone:818-242-9000
Practice Address - Fax:818-242-3972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARCF00031FMedicaid