Provider Demographics
NPI:1689967242
Name:RALLECA, GLENN
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:RALLECA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21615 BERENDO AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-1800
Mailing Address - Country:US
Mailing Address - Phone:714-744-1767
Mailing Address - Fax:951-371-5062
Practice Address - Street 1:21615 BERENDO AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-1800
Practice Address - Country:US
Practice Address - Phone:714-744-1767
Practice Address - Fax:951-371-5062
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN395986163WH0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0500XNursing Service ProvidersRegistered NurseHemodialysis