Healthcare Provider Details

I. General information

NPI: 1760668370
Provider Name (Legal Business Name): EMERALD DRYWALL LTD,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 DETROIT ST
BELLEFONTAINE OH
43311-1408
US

IV. Provider business mailing address

104 N DETROIT ST
BELLEFONTAINE OH
43311-1408
US

V. Phone/Fax

Practice location:
  • Phone: 937-593-8778
  • Fax: 937-593-9778
Mailing address:
  • Phone: 937-593-8778
  • Fax: 937-593-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name: MR. EDDIE C. SCIPIO
Title or Position: MEMBER
Credential:
Phone: 937-593-8778