Provider Demographics
NPI:1770827057
Name:EMPIRE GARDEN LYMPHEDEMA SERVICES & PRODUCTS, LLC
Entity Type:Organization
Organization Name:EMPIRE GARDEN LYMPHEDEMA SERVICES & PRODUCTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:EARLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CMLDT/LPN/LMT
Authorized Official - Phone:919-677-0767
Mailing Address - Street 1:539 KEISLER DR
Mailing Address - Street 2:204
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-9320
Mailing Address - Country:US
Mailing Address - Phone:919-677-0767
Mailing Address - Fax:919-651-9322
Practice Address - Street 1:539 KEISLER DR
Practice Address - Street 2:204
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-9320
Practice Address - Country:US
Practice Address - Phone:919-677-0767
Practice Address - Fax:919-651-9322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC71590332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies