Provider Demographics
NPI:1548440746
Name:GLORY HEALTHCARE SERVICES LLC
Entity type:Organization
Organization Name:GLORY HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BOLANLE
Authorized Official - Middle Name:OLADUNNI
Authorized Official - Last Name:SALAM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:678-365-1967
Mailing Address - Street 1:PO BOX 390301
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-0006
Mailing Address - Country:US
Mailing Address - Phone:678-365-1967
Mailing Address - Fax:770-554-6574
Practice Address - Street 1:7736 HAMPTON PLACE
Practice Address - Street 2:SUITE D
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6770
Practice Address - Country:US
Practice Address - Phone:678-365-1967
Practice Address - Fax:770-554-6577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA147-R-0327251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA871127462AMedicaid