MEDICARE: AMERICAN EAGLE TUSKAWILLA LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1932687258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICAN EAGLE TUSKAWILLA LLC

Provider Business Mailing Address
First Line	:	3819 HAWK CREST RD
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48103-4246
Country	:	US
Telephone Number	:	734-418-9027
Fax Number	:

Provider Business Practice Location Address
First Line	:	1016 WILLA SPRINGS DR
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-5214
Country	:	US
Telephone Number	:	734-418-9027
Fax Number	:

Authorized Official
Title or Position	:	ASSOCIATE
Name	:	CORY WAKE
Credential	:
Telephone Number	:	734-418-9027

Provider Enumeration Date	:	07/30/2018
Last Update Date	:	07/30/2018

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