Provider Demographics
NPI:1013124692
Name:VIJAK INC
Entity Type:Organization
Organization Name:VIJAK INC
Other - Org Name:GLENDALE HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIVIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ABAKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-461-0774
Mailing Address - Street 1:1706 N HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-2101
Mailing Address - Country:US
Mailing Address - Phone:727-246-1077
Mailing Address - Fax:727-442-8110
Practice Address - Street 1:1706 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-2101
Practice Address - Country:US
Practice Address - Phone:727-246-1077
Practice Address - Fax:727-442-8110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142327400Medicaid