MEDICARE: ESCENTUALS MEDICAL SUPPLY

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1871897603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESCENTUALS MEDICAL SUPPLY

Provider Business Mailing Address
First Line	:	5025 S EASTERN AVE STE 4
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-2309
Country	:	US
Telephone Number	:	702-245-1966
Fax Number	:	702-947-2248

Provider Business Practice Location Address
First Line	:	5025 S EASTERN AVE STE 4
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-2309
Country	:	US
Telephone Number	:	702-245-1966
Fax Number	:	702-947-2248

Authorized Official
Title or Position	:	DIRECTOR/MANAGER OF OPERATIONS
Name	:	MRS. BOLA N LEE
Credential	:	LPN
Telephone Number	:	702-245-1966

Provider Enumeration Date	:	01/10/2011
Last Update Date	:	06/07/2011

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