Provider Demographics
NPI:1932404555
Name:EMERALD KEY VILLA INC
Entity Type:Organization
Organization Name:EMERALD KEY VILLA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELINA
Authorized Official - Middle Name:QUEDADO
Authorized Official - Last Name:DOOLABH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:408-390-8533
Mailing Address - Street 1:PO BOX 32804
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95152
Mailing Address - Country:US
Mailing Address - Phone:408-390-8533
Mailing Address - Fax:
Practice Address - Street 1:15860 SIESTA VISTA DRIVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127
Practice Address - Country:US
Practice Address - Phone:408-390-8533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities