Provider Demographics
NPI:1922872266
Name:GLEN PARK AT GLENDORA
Entity Type:Organization
Organization Name:GLEN PARK AT GLENDORA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TILLMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PINK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:818-590-9827
Mailing Address - Street 1:1027 S CENTRAL AVE # 202
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-3957
Mailing Address - Country:US
Mailing Address - Phone:818-296-4646
Mailing Address - Fax:
Practice Address - Street 1:452 SELLERS ST
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-3846
Practice Address - Country:US
Practice Address - Phone:626-594-0152
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility