Provider Demographics
NPI:1578945440
Name:GLORIOSA MANAGEMENT LLC
Entity Type:Organization
Organization Name:GLORIOSA MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR AND DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHLOAS
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSI
Authorized Official - Suffix:
Authorized Official - Credentials:LAADC,NCAC,CCS
Authorized Official - Phone:951-427-4807
Mailing Address - Street 1:28202 CABOT RD
Mailing Address - Street 2:300
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-1222
Mailing Address - Country:US
Mailing Address - Phone:951-427-4807
Mailing Address - Fax:
Practice Address - Street 1:25466 GLORIOSA DR
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-4642
Practice Address - Country:US
Practice Address - Phone:951-427-4807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility