Provider Demographics
NPI:1548426372
Name:GLORIA CARR
Entity Type:Organization
Organization Name:GLORIA CARR
Other - Org Name:GLORIA CARR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:RN/LNC
Authorized Official - Phone:269-491-5647
Mailing Address - Street 1:404 VELVET AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-7050
Mailing Address - Country:US
Mailing Address - Phone:269-491-5647
Mailing Address - Fax:
Practice Address - Street 1:404 VELVET AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-7050
Practice Address - Country:US
Practice Address - Phone:269-491-5647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704200513273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit