Healthcare Provider Details

I. General information

NPI: 1053687533
Provider Name (Legal Business Name): EAGLE'S CROSSING ADULT DAY CENTER (MORA EAGLET)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 UNION ST S STE 4
MORA MN
55051-1579
US

IV. Provider business mailing address

133 UNION ST S STE 4
MORA MN
55051-1579
US

V. Phone/Fax

Practice location:
  • Phone: 320-285-3128
  • Fax:
Mailing address:
  • Phone: 320-285-3128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1062197
License Number StateMN

VIII. Authorized Official

Name: MRS. DIANE KAY KRAMER
Title or Position: OWNER/ ADULT DAY DIRECTOR
Credential:
Phone: 320-285-3128