Provider Demographics
NPI:1578605341
Name:EMERALD LAKE, INC
Entity Type:Organization
Organization Name:EMERALD LAKE, INC
Other - Org Name:EMERALD MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELECHI
Authorized Official - Middle Name:
Authorized Official - Last Name:AGWARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-678-6267
Mailing Address - Street 1:5243 W CHARLESTON BLVD STE 9
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1304
Mailing Address - Country:US
Mailing Address - Phone:702-678-6267
Mailing Address - Fax:702-474-7051
Practice Address - Street 1:5243 W CHARLESTON BLVD STE 9
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1304
Practice Address - Country:US
Practice Address - Phone:702-678-6267
Practice Address - Fax:702-474-7051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMP00814332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV3302694Medicaid
NV3302694Medicaid