Healthcare Provider Details

I. General information

NPI: 1972332674
Provider Name (Legal Business Name): FLY LIKE AN EAGLE OUTREACH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3317 E 8TH ST
LONG BEACH CA
90804-5008
US

IV. Provider business mailing address

3317 E 8TH ST
LONG BEACH CA
90804-5008
US

V. Phone/Fax

Practice location:
  • Phone: 310-945-8305
  • Fax:
Mailing address:
  • Phone: 310-945-8305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: JOLLY GLOVER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 310-945-8305