| A Glorious Place Llc | |
|
3203a Corporate Ct Ellicott City MD 21042-2247 | |
| (410) 205-2458 | |
| Not Available |
| Full Name | A Glorious Place Llc |
|---|---|
| Speciality | Nurse Practitioner |
| Location | 3203a Corporate Ct, Ellicott City, Maryland |
| Authorized Official Name and Position | Glory Tataw (CEO) |
| Authorized Official Contact | 4102052458 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| A Glorious Place Llc 3203a Corporate Ct Ellicott City MD 21042-2247 Ph: (410) 205-2458 | A Glorious Place Llc 3203a Corporate Ct Ellicott City MD 21042-2247 Ph: (410) 205-2458 |
| NPI Number | 1043952880 |
|---|---|
| Provider Enumeration Date | 04/12/2022 |
| Last Update Date | 09/16/2022 |
| Certification Date | 09/16/2022 |
| Medicare PECOS PAC ID | 4587040456 |
|---|---|
| Medicare Enrollment ID | O20220929001683 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1043952880 | NPI | - | NPPES |
| Provider Name | Glory Tataw |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1033782115 PECOS PAC ID: 7113303082 Enrollment ID: I20220929001755 |
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