Healthcare Provider Details

I. General information

NPI: 1417861923
Provider Name (Legal Business Name): GLOW WITHIN WELLNESS COLLECTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 GRAYBURN AVE
LOS ANGELES CA
90008-1940
US

IV. Provider business mailing address

3825 GRAYBURN AVE
LOS ANGELES CA
90008-1940
US

V. Phone/Fax

Practice location:
  • Phone: 310-407-9283
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANTACASIA THOMAS
Title or Position: OWNER / MANAGING MEMBER
Credential:
Phone: 310-407-9283