MEDICARE: GLORYLAND HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)
2	3104A0630X	Assisted Living Facility (Behavioral Disturbances)

General Provider Information

NPI Number	:	1497369425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLORYLAND HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	17222 MERRY SONG CT
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77407-2963
Country	:	US
Telephone Number	:	513-526-2468
Fax Number	:

Provider Business Practice Location Address
First Line	:	17222 MERRY SONG CT
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77407-2963
Country	:	US
Telephone Number	:	513-526-2468
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	BENJAMIN EZENTO
Credential	:
Telephone Number	:	513-526-2468

Provider Enumeration Date	:	09/08/2020
Last Update Date	:	09/08/2020

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Directions to “GLORYLAND HEALTHCARE LLC ” Practice Location

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