Provider Demographics
NPI:1861400780
Name:MALCOLM GLEN CORP
Entity type:Organization
Organization Name:MALCOLM GLEN CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:HIS
Authorized Official - Phone:909-986-9635
Mailing Address - Street 1:528 NO PALM AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3218
Mailing Address - Country:US
Mailing Address - Phone:909-986-9635
Mailing Address - Fax:909-391-5873
Practice Address - Street 1:528 NO PALM AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3218
Practice Address - Country:US
Practice Address - Phone:909-986-9635
Practice Address - Fax:909-391-5873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA3682237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04705ZOtherBLUE SHIELD
CAHA0036820Medicaid