Healthcare Provider Details

I. General information

NPI: 1235315664
Provider Name (Legal Business Name): KATHRYN ROSE EAGLE LDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 TINKERVILLE RD
GLASGOW VA
24555-2962
US

IV. Provider business mailing address

166 TINKERVILLE RD
GLASGOW VA
24555-2962
US

V. Phone/Fax

Practice location:
  • Phone: 540-291-3373
  • Fax: 540-291-3373
Mailing address:
  • Phone: 540-291-3373
  • Fax: 540-291-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number1101003356
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: