Provider Demographics
NPI:1184122012
Name:EMANCIPATION HEALTH & WELLNESS LLC
Entity type:Organization
Organization Name:EMANCIPATION HEALTH & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:TYRONE
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-756-9965
Mailing Address - Street 1:222 S RAINBOW BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-5343
Mailing Address - Country:US
Mailing Address - Phone:702-478-8205
Mailing Address - Fax:
Practice Address - Street 1:222 S RAINBOW BLVD STE 111
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-5343
Practice Address - Country:US
Practice Address - Phone:702-478-8205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20181050463251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health