MEDICARE: GLORY CENTER, P.A.

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	261Q00000X	Clinic/Center		FL

General Provider Information

NPI Number	:	1558617399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLORY CENTER, P.A.

Provider Business Mailing Address
First Line	:	6641 MADISON ST
Second Line	:	SUITE 3
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34652-1966
Country	:	US
Telephone Number	:	727-232-0826
Fax Number	:	727-597-8487

Provider Business Practice Location Address
First Line	:	6641 MADISON ST
Second Line	:	SUITE 3
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34652-1966
Country	:	US
Telephone Number	:	727-232-0826
Fax Number	:	727-597-8487

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DAVID O IKUDAYISI
Credential	:	M.D.
Telephone Number	:	813-495-2234

Provider Enumeration Date	:	07/31/2012
Last Update Date	:	02/05/2013

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