Healthcare Provider Details

I. General information

NPI: 1801445481
Provider Name (Legal Business Name): GLACIER BAY HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 PETERSEN AVE
SAN JOSE CA
95129-4844
US

IV. Provider business mailing address

16885 W BERNARDO DR STE 216
SAN DIEGO CA
92127-1620
US

V. Phone/Fax

Practice location:
  • Phone: 858-798-5700
  • Fax:
Mailing address:
  • Phone: 760-331-3177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: TOBY TILFORD
Title or Position: CO-CEO
Credential:
Phone: 858-774-8342