Provider Demographics
NPI:1316101843
Name:GLENDORA CLINIC
Entity type:Organization
Organization Name:GLENDORA CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:662-345-2334
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:CORNER OF GIBSON AND WESTBROOKS AVE
Mailing Address - City:GLENDORA
Mailing Address - State:MS
Mailing Address - Zip Code:38928-0189
Mailing Address - Country:US
Mailing Address - Phone:662-375-8878
Mailing Address - Fax:
Practice Address - Street 1:44 WESTBROOKS AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:MS
Practice Address - Zip Code:38928
Practice Address - Country:US
Practice Address - Phone:662-375-8878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TUTWILER CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR767376363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014072Medicaid
MSC02930Medicare PIN
MS09014072Medicaid