MEDICARE: MALCOLM GLEN CORP

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	237700000X	Hearing Instrument Specialist	HA3682	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ04705Z	OTHER	CA	BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861400780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALCOLM GLEN CORP

Provider Business Mailing Address
First Line	:	528 NO PALM AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91762-3218
Country	:	US
Telephone Number	:	909-986-9635
Fax Number	:	909-391-5873

Provider Business Practice Location Address
First Line	:	528 NO PALM AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91762-3218
Country	:	US
Telephone Number	:	909-986-9635
Fax Number	:	909-391-5873

Authorized Official
Title or Position	:	CFO
Name	:	MR. GARY M JONES
Credential	:	HIS
Telephone Number	:	909-986-9635

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	08/22/2020

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Directions to “MALCOLM GLEN CORP ” Practice Location

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