Healthcare Provider Details

I. General information

NPI: 1659529899
Provider Name (Legal Business Name): GLENNA TOLBERT MD A MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17609 VENTURA BLVD SUITE 114
ENCINO CA
91316-5119
US

IV. Provider business mailing address

17609 VENTURA BLVD SUITE 114
ENCINO CA
91316-5119
US

V. Phone/Fax

Practice location:
  • Phone: 818-784-7197
  • Fax: 818-784-3060
Mailing address:
  • Phone: 818-784-7197
  • Fax: 818-784-3060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG70820
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License NumberG70820
License Number StateCA

VIII. Authorized Official

Name: DR. GLENNA PATRISE TOLBERT
Title or Position: PRESIDENT MEDICAL DIRECTOR
Credential: MD
Phone: 818-784-7197