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General NPI Number Information
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NPI Number | 1295956233
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Entity Type | Organization
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Legal Business Name | EMERALD LAKE, INC
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 500 S MARTIN L KING BLVD STE D
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City | LAS VEGAS
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State | NV
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Zip | 89106-4424
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Country | US
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Telephone | 702-678-6776
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Fax | 702-678-6661
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Provider Business Mailing Address
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Address Line | 500 S MARTIN L KING BLVD STE D
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City | LAS VEGAS
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State | NV
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Zip | 89106-4424
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Country | US
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Telephone | 702-678-6776
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Fax | 702-678-6661
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Authorized Official
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Title or Position | MANAGER
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Name | MARCEL EZEOKE
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Credential | RPH
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Telephone | 702-678-6776
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State | NV
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