Healthcare Provider Details

I. General information

NPI: 1871897603
Provider Name (Legal Business Name): ESCENTUALS MEDICAL SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 S EASTERN AVE STE 4
LAS VEGAS NV
89119-2309
US

IV. Provider business mailing address

5025 S EASTERN AVE STE 4
LAS VEGAS NV
89119-2309
US

V. Phone/Fax

Practice location:
  • Phone: 702-245-1966
  • Fax: 702-947-2248
Mailing address:
  • Phone: 702-245-1966
  • Fax: 702-947-2248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MRS. BOLA N LEE
Title or Position: DIRECTOR/MANAGER OF OPERATIONS
Credential: LPN
Phone: 702-245-1966