Provider Demographics
NPI:1427472364
Name:GLORY MEDCLINIC, LLC
Entity type:Organization
Organization Name:GLORY MEDCLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:OMOTAYO
Authorized Official - Last Name:IKUDAYISI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-932-9798
Mailing Address - Street 1:8019 N HIMES AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2712
Mailing Address - Country:US
Mailing Address - Phone:813-932-9798
Mailing Address - Fax:813-935-5178
Practice Address - Street 1:8019 N HIMES AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2712
Practice Address - Country:US
Practice Address - Phone:813-932-9798
Practice Address - Fax:813-935-5178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service