Healthcare Provider Details

I. General information

NPI: 1699312314
Provider Name (Legal Business Name): CARDINAL SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2019
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2512 E EVERGREEN BLVD
VANCOUVER WA
98661-4323
US

IV. Provider business mailing address

2804 S LAKEVIEW DR
CEDAR HILL TX
75104-8233
US

V. Phone/Fax

Practice location:
  • Phone: 972-503-4109
  • Fax: 972-449-0500
Mailing address:
  • Phone: 972-503-4109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. NWAMAKA LARVINE EMERUEM
Title or Position: DIRECTOR
Credential: DNP
Phone: 972-503-4109