MEDICARE: EAGLES NEST TRUCK STATION INC

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	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1041060001	OTHER		DME

General Provider Information

NPI Number	:	1710989462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLES NEST TRUCK STATION INC

Provider Business Mailing Address
First Line	:	PO BOX 929
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-0929
Country	:	US
Telephone Number	:	912-748-6842
Fax Number	:	912-748-5214

Provider Business Practice Location Address
First Line	:	508 S ROGERS ST
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-3116
Country	:	US
Telephone Number	:	912-748-6842
Fax Number	:	912-748-5214

Authorized Official
Title or Position	:	CEO
Name	:	MR. THOMAS W PENLEY SR.
Credential	:
Telephone Number	:	706-855-1773

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	08/22/2020

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