Healthcare Provider Details

I. General information

NPI: 1184338774
Provider Name (Legal Business Name): GLORIOUS EAGLES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 08/12/2023
Certification Date: 08/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2119 110TH LN NW
COON RAPIDS MN
55433-4173
US

IV. Provider business mailing address

2119 110TH LN NW
COON RAPIDS MN
55433-4173
US

V. Phone/Fax

Practice location:
  • Phone: 612-456-6090
  • Fax:
Mailing address:
  • Phone: 612-456-6090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: PROF. SAMSON ALAYANDE
Title or Position: PRESIDENT
Credential:
Phone: 612-456-6090