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General NPI Number Information
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NPI Number | 1184122012
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Entity Type | Organization
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Legal Business Name | EMANCIPATION HEALTH & WELLNESS LLC
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Dates
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Enumeration Date | 01/25/2018
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Last Update Date | 01/25/2018
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Provider Practice Location Address
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Address Line | 222 S RAINBOW BLVD STE 111
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City | LAS VEGAS
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State | NV
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Zip | 89145-5343
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Country | US
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Telephone | 702-478-8205
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Fax |
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Provider Business Mailing Address
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Address Line | 222 S RAINBOW BLVD STE 111
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City | LAS VEGAS
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State | NV
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Zip | 89145-5343
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Country | US
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Telephone | 702-478-8205
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GLEN TYRONE CHAMBERS
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Credential |
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Telephone | 310-756-9965
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | NV20181050463
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License Number State | NV
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