Healthcare Provider Details

I. General information

NPI: 1114755923
Provider Name (Legal Business Name): EAGLE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2745 HERSCHEL ST N A109
ROSEVILLE MN
55113
US

IV. Provider business mailing address

3800 AMERICAN BLVD W STE 1500
BLOOMINGTON MN
55431-4429
US

V. Phone/Fax

Practice location:
  • Phone: 614-596-3566
  • Fax:
Mailing address:
  • Phone: 614-596-3566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: OMAR ELEYE
Title or Position: CEO
Credential:
Phone: 614-596-3566