Active NPI
Glendora Grand, Inc.
- Skilled Nursing Facility
- Glendora, CA
National Provider Identifier
1497077739
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Skilled Nursing Facility
- License
- 950000079
- Legal business name
- GLENDORA GRAND, INC.
- Practice address
- 805 W. Arrow Highway
Glendora, CA 91740-5413 - Phone
- (626) 331-0781
- Fax
- (626) 332-8835
- NPI assigned
- Feb 26, 2010
- Last updated
- Mar 25, 2014
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Ms. Vicki P Rollins, RN
- Title
- Vice-President
- Phone
- (626) 331-0781
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Skilled Nursing Facility | 314000000X | 950000079 | CA | Primary |
Addresses
Primary practice location
805 W. Arrow Highway
Glendora, CA 91740-5413
Mailing address
805 W. Arrow Highway
Glendora, CA 91740-5413
Phone (626) 331-0781
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100616000271 | CA | Part A Provider - Skilled Nursing Facility | 9436289584 | Practice locations: Glendora, CA |
NPI to CCN mapping 1
The Medicare certification numbers (CCNs) connected to NPI 1497077739. Details of each certification follow.
Skilled nursing facility certification: CCN 056079
- Legal name
- GLENDORA GRAND, INC.
- Doing business as
- N/A
- Certification status
- Active
- Provider type (POS)
- Nursing home – SNF/NF dual certification
- Participating since
- Jan 1, 1972
- Last certification
- Aug 2, 2024
- Beds
- 342
- Ownership / control type
- Corporation
- Organization structure
- Corporation
- Incorporated
- Jul 27, 2008 in CA
- Enrollment address
- 805 W Arrow Hwy
Glendora, CA 91740-5413 - Nursing home name
- GLENDORA GRAND, INC
- Affiliated entity
- ROLLINS-NELSON HEALTHCARE MANAGEMENT
Care Compare: Nursing home
Medicare Care Compare- Listed as
- Glendora Grand, Inc
- Overall star rating
- Health inspections
- Staffing
- Quality measures
- Type
- Medicare and Medicaid
- Ownership
- For profit - Corporation
- Certified
- Jan 1, 1972
- Medicare certification status
- Active
- Certified beds
- 342
- Chain
- Rollins-Nelson Healthcare Management
- Penalties (3 years)
- 6
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D0716080 | Glendora Grand, Inc | Certificate of waiver | Aug 31, 2026 |
National Provider Directory
National Provider DirectoryOwnership & related parties
All disclosed owners & managing parties 7
As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.
| Name | Role | Since | Share |
|---|---|---|---|
| Karen Pagela-Zambrano | Operational/Managerial Control | Apr 10, 2022 | |
| Adp of the SNF | Apr 10, 2022 | ||
| William a Nelson | 5% Or Greater Direct Ownership Interest | Dec 11, 2009 | 50% |
| 5% Or Greater Mortgage Interest | Dec 11, 2009 | 50% | |
| Corporate Officer | Dec 11, 2009 | 50% | |
| Adp of the SNF | Dec 11, 2009 | ||
| Direct Ownership Interest | Dec 11, 2009 | 50% | |
| Vicki P Rollins | 5% Or Greater Direct Ownership Interest | Dec 11, 2009 | 50% |
| 5% Or Greater Mortgage Interest | Dec 11, 2009 | 50% | |
| Corporate Officer | Dec 11, 2009 | 50% | |
| Adp of the SNF | Dec 11, 2009 | ||
| Direct Ownership Interest | Dec 11, 2009 | 50% | |
| Lakshman Makandura | Operational/Managerial Control | Jul 22, 2010 | |
| Adp of the SNF | Jul 22, 2010 | ||
| Glendora Grand Property, LLC | 5% Or Greater Mortgage Interest | Dec 11, 2009 | 100% |
| Adp of the SNF | Dec 11, 2009 | ||
| Glendora Grand, Inc. | 5% Or Greater Direct Ownership Interest | Dec 11, 2009 | 100% |
| Gladys Lazo | Operational/Managerial Control | Feb 1, 2015 | |
| Adp of the SNF | Feb 1, 2015 |
Practitioners & affiliated clinicians
Affiliated clinicians 6
Clinicians who list this facility as an affiliation in Medicare Care Compare.
-
- Anatomic Pathology & Clinical Pathology Physician
- Carson, CA
- NPI 1114140233
Nursing home
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1267142400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1395705600000",
"number": "1497077739",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "805 W. ARROW HIGHWAY",
"city": "GLENDORA",
"state": "CA",
"postal_code": "917405413",
"telephone_number": "626-331-0781",
"fax_number": "626-332-8835"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "805 W. ARROW HIGHWAY",
"city": "GLENDORA",
"state": "CA",
"postal_code": "917405413",
"telephone_number": "626-331-0781",
"fax_number": "626-332-8835"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "GLENDORA GRAND, INC.",
"organizational_subpart": "NO",
"enumeration_date": "2010-02-26",
"last_updated": "2014-03-25",
"status": "A",
"authorized_official_last_name": "ROLLINS",
"authorized_official_first_name": "VICKI",
"authorized_official_middle_name": "P",
"authorized_official_title_or_position": "VICE-PRESIDENT",
"authorized_official_telephone_number": "626-331-0781",
"authorized_official_name_prefix": "Ms.",
"authorized_official_credential": "RN"
},
"taxonomies": [
{
"code": "314000000X",
"taxonomy_group": "",
"desc": "Skilled Nursing Facility",
"state": "CA",
"license": "950000079",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Glendora, CA
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- Glendora Family Therapy, Inc
- Glendora Medical Associates
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Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.