MEDICARE: EAGLES NEST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253J00000X	Foster Care Agency	AF190277334	MI

General Provider Information

NPI Number	:	1679718639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLES NEST

Provider Business Mailing Address
First Line	:	13282 S HINMAN RD
Second Line	:
City	:	EAGLE
State	:	MI
Zip	:	48822-9637
Country	:	US
Telephone Number	:	517-626-2190
Fax Number	:

Provider Business Practice Location Address
First Line	:	13282 S HINMAN RD
Second Line	:
City	:	EAGLE
State	:	MI
Zip	:	48822-9637
Country	:	US
Telephone Number	:	517-626-2190
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KACIE SHAW
Credential	:
Telephone Number	:	517-626-2190

Provider Enumeration Date	:	12/04/2008
Last Update Date	:	12/04/2008

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Directions to “EAGLES NEST ” Practice Location

Language	Start Address	Practice Location

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