Provider Demographics
NPI:1023235793
Name:GLORY REHABILITATION & CONSULTANCY SERVICES,INC.,
Entity type:Organization
Organization Name:GLORY REHABILITATION & CONSULTANCY SERVICES,INC.,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:OLUSEGUN
Authorized Official - Last Name:ODUSAGA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:219-689-3390
Mailing Address - Street 1:9715 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-5452
Mailing Address - Country:US
Mailing Address - Phone:219-689-3390
Mailing Address - Fax:219-226-0938
Practice Address - Street 1:9715 MONROE ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-5452
Practice Address - Country:US
Practice Address - Phone:219-689-3390
Practice Address - Fax:219-226-0938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005317A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN188090Medicare ID - Type UnspecifiedMEDICARE PART B CARRIER