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General NPI Number Information
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NPI Number | 1831437763
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Entity Type | Organization
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Legal Business Name | EMPIRE GARDEN LYMPHEDEMA SERVICES & PRODUCTS, LLC
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Dates
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Enumeration Date | 01/28/2013
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Last Update Date | 01/28/2013
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Provider Practice Location Address
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Address Line | 539 KEISLER DR SUITE 204
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City | CARY
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State | NC
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Zip | 27518-9320
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Country | US
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Telephone | 919-677-0767
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Fax |
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Provider Business Mailing Address
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Address Line | 539 KEISLER DR STE 204
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City | CARY
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State | NC
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Zip | 27518-9320
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR/CHIEF THERAPIST
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Name | MISS EARLINE JACKSON
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Credential |
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Telephone | 919-677-0767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 71590
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License Number State | NC
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