=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932395092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLENVILLE MEDICAL GROUP, A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2007
-----------------------------------------------------
Last Update Date | 12/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1531 GLENVILLE DR
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90035-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-551-2750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1531 GLENVILLE DR
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90035-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-551-2750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER
-----------------------------------------------------
Name | MS. JOY VERNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-551-2750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------