Provider Demographics
NPI:1285347575
Name:GLORIOUS CARE PROJECT LLC
Entity type:Organization
Organization Name:GLORIOUS CARE PROJECT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FONUTCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-212-2636
Mailing Address - Street 1:1087 W AVALON CANYON DR
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-6706
Mailing Address - Country:US
Mailing Address - Phone:480-212-2636
Mailing Address - Fax:
Practice Address - Street 1:1171 E RIVERTON PL
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6578
Practice Address - Country:US
Practice Address - Phone:480-212-2636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLORIOUS CARE PROJECT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-02
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
5874OtherBCBS