Healthcare Provider Details

I. General information

NPI: 1336894393
Provider Name (Legal Business Name): EAGLE EYE GROUP HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 02/18/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 EAGLE EYE GROUP HOME, INC
KISSIMMEE FL
34759
US

IV. Provider business mailing address

415 EAGLE DR
KISSIMMEE FL
34759-4432
US

V. Phone/Fax

Practice location:
  • Phone: 863-547-4886
  • Fax: 863-547-4993
Mailing address:
  • Phone: 863-547-4886
  • Fax: 863-547-4993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL

VIII. Authorized Official

Name: PAULETTE ANNMARIE ANNIKEY
Title or Position: CEO
Credential: MEDICAID PROVIDER
Phone: 321-978-6509