Provider Demographics
NPI:1780489112
Name:GLENDALE REDBIRD CO
Entity type:Organization
Organization Name:GLENDALE REDBIRD CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MYDUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, RN
Authorized Official - Phone:480-918-4775
Mailing Address - Street 1:6637 N 58TH DR APT 3
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-3900
Mailing Address - Country:US
Mailing Address - Phone:480-918-4775
Mailing Address - Fax:
Practice Address - Street 1:6637 N 58TH DR APT 3
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-3900
Practice Address - Country:US
Practice Address - Phone:480-918-4775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADADVANTAGE A PROFESSIONAL CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ167030Medicaid