Provider Demographics
NPI:1922135680
Name:EAST VALLEY GLENDORA HOSPITAL LLC
Entity Type:Organization
Organization Name:EAST VALLEY GLENDORA HOSPITAL LLC
Other - Org Name:GLENDORA COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:HEATHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-235-4332
Mailing Address - Street 1:3300 E GUASTI RD FL 3
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-8655
Mailing Address - Country:US
Mailing Address - Phone:909-235-4400
Mailing Address - Fax:909-235-4419
Practice Address - Street 1:150 W ROUTE 66
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6207
Practice Address - Country:US
Practice Address - Phone:626-852-6125
Practice Address - Fax:626-852-5055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000060273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSM30205IMedicaid
CAZZT30205IMedicaid
CA05S205Medicare Oscar/Certification