Healthcare Provider Details

I. General information

NPI: 1700051711
Provider Name (Legal Business Name): EAGLE DANCER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 S COLLEGE AVE
BLOOMINGTON IN
47403-1513
US

IV. Provider business mailing address

414 S COLLEGE AVE
BLOOMINGTON IN
47403-1513
US

V. Phone/Fax

Practice location:
  • Phone: 812-331-1962
  • Fax: 812-332-1949
Mailing address:
  • Phone: 812-331-1962
  • Fax: 812-332-1949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number280-B
License Number StateIN

VIII. Authorized Official

Name: RAYMOND STIDD
Title or Position: PROVIDER
Credential: DPM
Phone: 812-330-0909