Provider Demographics
NPI:1972768158
Name:GLENDALE MUTUAL CARE CLINIC
Entity Type:Organization
Organization Name:GLENDALE MUTUAL CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JARLATH
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-646-8233
Mailing Address - Street 1:PO BOX 10717
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91209-3717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 N MARYLAND AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4261
Practice Address - Country:US
Practice Address - Phone:626-616-6642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-27
Last Update Date:2008-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98448261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care