MEDICARE: GLOCKSTON 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1568183788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLOCKSTON LLC

Provider Business Mailing Address
First Line	:	2266 LAVA RIDGE CT
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-2856
Country	:	US
Telephone Number	:	949-508-8370
Fax Number	:

Provider Business Practice Location Address
First Line	:	750 AUBURN RAVINE RD
Second Line	:
City	:	AUBURN
State	:	CA
Zip	:	95603-3820
Country	:	US
Telephone Number	:	530-823-6131
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MR. DAN BUSHNELL
Credential	:
Telephone Number	:	949-508-8370

Provider Enumeration Date	:	09/06/2022
Last Update Date	:	09/06/2022

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Directions to “GLOCKSTON LLC ” Practice Location

Language	Start Address	Practice Location

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