Provider Demographics
NPI:1700622305
Name:BRON SUSBILLA, GLORIA JOYCE
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:JOYCE
Last Name:BRON SUSBILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 ELM ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-2508
Mailing Address - Country:US
Mailing Address - Phone:916-770-5378
Mailing Address - Fax:
Practice Address - Street 1:256 ELM ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-2508
Practice Address - Country:US
Practice Address - Phone:916-770-5378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315002960310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility