MEDICARE: BOUNDLESS EAGLES OUTREACH MINISTRY

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	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1992033625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOUNDLESS EAGLES OUTREACH MINISTRY

Provider Business Mailing Address
First Line	:	14175 LONGACRE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-1356
Country	:	US
Telephone Number	:	313-835-0275
Fax Number	:

Provider Business Practice Location Address
First Line	:	14175 LONGACRE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-1356
Country	:	US
Telephone Number	:	313-835-0275
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. KENNETH FLOYD
Credential	:
Telephone Number	:	313-835-0275

Provider Enumeration Date	:	11/18/2009
Last Update Date	:	11/18/2009

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