MEDICARE: EMERALD BLUE HEALTH CARE SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor		TX

General Provider Information

NPI Number	:	1043204530
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD BLUE HEALTH CARE SERVICES

Provider Business Mailing Address
First Line	:	822 GARDEN TRACE LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-6342
Country	:	US
Telephone Number	:	832-876-1360
Fax Number	:	713-426-3603

Provider Business Practice Location Address
First Line	:	822 GARDEN TRACE LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-6342
Country	:	US
Telephone Number	:	832-876-1360
Fax Number	:	713-426-3603

Authorized Official
Title or Position	:	OWNER/PROGRAM DIRECTOR
Name	:	MRS. MYTOIA MOSS
Credential	:
Telephone Number	:	832-876-1360

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	08/22/2020

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