Provider Demographics
NPI:1053776575
Name:TENISHA GLASS
Entity type:Organization
Organization Name:TENISHA GLASS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE
Authorized Official - Prefix:
Authorized Official - First Name:TENISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-551-1822
Mailing Address - Street 1:20371 LORAIN RD APT E5
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-3455
Mailing Address - Country:US
Mailing Address - Phone:216-551-1822
Mailing Address - Fax:
Practice Address - Street 1:20371 LORAIN RD APT E5
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-3455
Practice Address - Country:US
Practice Address - Phone:216-551-1822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400078860202311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3062939Medicaid