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General NPI Number Information
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NPI Number | 1417132812
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Entity Type | Organization
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Legal Business Name | GLEN PARK AT GLENDALE - MARIPOSA ST
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Dates
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Enumeration Date | 01/03/2008
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Last Update Date | 01/08/2015
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Provider Practice Location Address
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Address Line | 1220 MARIPOSA ST GLEN PARK WEST RETIREMENT COMMUNITY INC
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City | GLENDALE
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State | CA
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Zip | 91205-3245
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Country | US
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Telephone | 818-242-9000
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Fax | 818-242-3972
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Provider Business Mailing Address
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Address Line | 1220 MARIPOSA ST GLEN PARK WEST RETIREMENT COMMUNITY INC
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City | GLENDALE
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State | CA
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Zip | 91205-3245
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Country | US
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Telephone | 818-242-9000
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Fax | 818-242-3972
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. TILLMAN NMN PINK JR.
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Credential |
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Telephone | 818-242-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 191222675
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License Number State | CA
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