MEDICARE: EMERALD LAKE, INC

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	332BX2000X	Oxygen Equipment & Supplies (DME)	MP00814	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578605341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD LAKE, INC

Provider Business Mailing Address
First Line	:	5243 W CHARLESTON BLVD STE 9
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1304
Country	:	US
Telephone Number	:	702-678-6267
Fax Number	:	702-474-7051

Provider Business Practice Location Address
First Line	:	5243 W CHARLESTON BLVD STE 9
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1304
Country	:	US
Telephone Number	:	702-678-6267
Fax Number	:	702-474-7051

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. KELECHI AGWARA
Credential	:
Telephone Number	:	702-678-6267

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	12/03/2015

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Directions to “EMERALD LAKE, INC ” Practice Location

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