Provider Demographics
NPI:1750017166
Name:EMMAUS VILLA, LLC
Entity type:Organization
Organization Name:EMMAUS VILLA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARATHUNDIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-873-2561
Mailing Address - Street 1:6271 NW 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-2702
Mailing Address - Country:US
Mailing Address - Phone:954-873-2561
Mailing Address - Fax:954-247-9560
Practice Address - Street 1:6271 NW 15TH ST
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-2702
Practice Address - Country:US
Practice Address - Phone:954-873-2561
Practice Address - Fax:954-247-9560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012183500Medicaid