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General NPI Number Information
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NPI Number | 1225001423
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Entity Type | Organization
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Legal Business Name | GLENDALE OPHTHALMOLOGY ASC LP
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Dates
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Enumeration Date | 02/08/2006
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Last Update Date | 09/07/2023
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Provider Practice Location Address
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Address Line | 607 N CENTRAL AVE SUITE 103
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City | GLENDALE
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State | CA
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Zip | 91203-1804
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Country | US
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Telephone | 818-956-1010
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Fax | 818-543-6083
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Provider Business Mailing Address
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Address Line | 607 N CENTRAL AVE SUITE 103
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City | GLENDALE
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State | CA
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Zip | 91203-1804
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Country | US
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Telephone | 818-956-1010
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Fax | 818-543-6083
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. PHILLIP A CLENDENIN
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Credential |
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Telephone | 615-665-1283
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 930000717
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License Number State | CA
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