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General NPI Number Information
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NPI Number | 1659133734
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Entity Type | Organization
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Legal Business Name | ETHEREAL EMPIRE LLC
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Dates
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Enumeration Date | 01/25/2024
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Last Update Date | 01/25/2024
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Provider Practice Location Address
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Address Line | 1501 PERDIDO DR
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City | EULESS
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State | TX
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Zip | 76039-1415
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Country | US
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Telephone | 817-785-9479
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Fax |
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Provider Business Mailing Address
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Address Line | 1501 PERDIDO DR
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City | EULESS
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State | TX
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Zip | 76039-1415
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Country | US
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Telephone | 817-785-9479
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KHATIRA ALI
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Credential |
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Telephone | 817-785-9479
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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 |
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