Healthcare Provider Details

I. General information

NPI: 1942011978
Provider Name (Legal Business Name): EAGLES WINGS HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1366 WOODLAND PASS
FORT WAYNE IN
46818-6903
US

IV. Provider business mailing address

1366 WOODLAND PASS
FORT WAYNE IN
46818-6903
US

V. Phone/Fax

Practice location:
  • Phone: 417-460-8801
  • Fax:
Mailing address:
  • Phone: 417-460-8801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MISS MAYOKUN ADEYALE
Title or Position: MANAGER
Credential:
Phone: 317-460-8801