Healthcare Provider Details

I. General information

NPI: 1679718639
Provider Name (Legal Business Name): EAGLES NEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2008
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13282 S HINMAN RD
EAGLE MI
48822-9637
US

IV. Provider business mailing address

13282 S HINMAN RD
EAGLE MI
48822-9637
US

V. Phone/Fax

Practice location:
  • Phone: 517-626-2190
  • Fax:
Mailing address:
  • Phone: 517-626-2190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License NumberAF190277334
License Number StateMI

VIII. Authorized Official

Name: KACIE SHAW
Title or Position: OWNER
Credential:
Phone: 517-626-2190