MEDICARE: GLORY TREATMENT CENTER 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1679268262
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLORY TREATMENT CENTER LLC

Provider Business Mailing Address
First Line	:	9439 W VIRGINIA AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85037-4433
Country	:	US
Telephone Number	:	602-516-4473
Fax Number	:

Provider Business Practice Location Address
First Line	:	3104 W GLENDALE AVE STE 10
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-8317
Country	:	US
Telephone Number	:	602-516-4473
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	HABTOM H HADISH
Credential	:
Telephone Number	:	602-516-4473

Provider Enumeration Date	:	04/10/2023
Last Update Date	:	04/10/2023

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