MEDICARE: EMERALD HOME CARE AGENCY, LLC

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1417682386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD HOME CARE AGENCY, LLC

Provider Business Mailing Address
First Line	:	6613 CAUDELL PL
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-2523
Country	:	US
Telephone Number	:	980-226-8686
Fax Number	:

Provider Business Practice Location Address
First Line	:	6613 CAUDELL PL
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-2523
Country	:	US
Telephone Number	:	980-226-8686
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	METHUSELAH EMERLAD DIXON
Credential	:
Telephone Number	:	980-226-8686

Provider Enumeration Date	:	07/23/2022
Last Update Date	:	09/22/2022

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