Healthcare Provider Details

I. General information

NPI: 1720615693
Provider Name (Legal Business Name): EMERALD MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 20TH ST STE 378
VERO BEACH FL
32966-1014
US

IV. Provider business mailing address

2160 58TH AVE # 318
VERO BEACH FL
32966-4647
US

V. Phone/Fax

Practice location:
  • Phone: 772-307-9840
  • Fax: 786-756-8419
Mailing address:
  • Phone: 772-307-9840
  • Fax: 786-756-8419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. AMANDA LYNN ESPINAL
Title or Position: COO
Credential:
Phone: 772-307-9840