Provider Demographics
NPI:1598590291
Name:GLENDALE REDBIRD CO
Entity type:Organization
Organization Name:GLENDALE REDBIRD CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:MYDUNG
Authorized Official - Middle Name:THI
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-624-5207
Mailing Address - Street 1:6637 N 58TH DR APT 3
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-3900
Mailing Address - Country:US
Mailing Address - Phone:623-624-5207
Mailing Address - Fax:
Practice Address - Street 1:6637 N 58TH DR APT 7
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-3900
Practice Address - Country:US
Practice Address - Phone:623-624-5179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-04
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Multi-Specialty
No347C00000XTransportation ServicesPrivate VehicleGroup - Multi-Specialty
No347E00000XTransportation ServicesTransportation Broker
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education