=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003092115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLOVE HOUSE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2008
-----------------------------------------------------
Last Update Date | 01/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 FRANKLIN ST
-----------------------------------------------------
City | ELMIRA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14904-1706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-734-5238
-----------------------------------------------------
Fax | 607-737-0884
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 FRANKLIN ST
-----------------------------------------------------
City | ELMIRA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14904-1706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-734-5238
-----------------------------------------------------
Fax | 607-737-0884
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MR. PATRICK MURPHY J
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 607-734-5238
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number | 7468431
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
=====================================================
Legacy Identifiers
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 01544201
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | NY
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
=====================================================
Proprietary Identifiers Ever Reported
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 01544201
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | NY
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------