Healthcare Provider Details

I. General information

NPI: 1598590291
Provider Name (Legal Business Name): GLENDALE REDBIRD CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6637 N 58TH DR APT 7
GLENDALE AZ
85301-3900
US

IV. Provider business mailing address

6637 N 58TH DR APT 3
GLENDALE AZ
85301-3900
US

V. Phone/Fax

Practice location:
  • Phone: 623-624-5179
  • Fax:
Mailing address:
  • Phone: 623-624-5207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: MS. MYDUNG THI PHAN
Title or Position: CFO
Credential:
Phone: 623-624-5207