Healthcare Provider Details

I. General information

NPI: 1225378292
Provider Name (Legal Business Name): ANDY L. EAGLE, JR.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15153 COUNTY LINE RD
KEYSVILLE VA
23947-4402
US

IV. Provider business mailing address

15153 COUNTY LINE RD
KEYSVILLE VA
23947-4402
US

V. Phone/Fax

Practice location:
  • Phone: 434-736-8887
  • Fax:
Mailing address:
  • Phone: 434-736-8887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number2705037850
License Number StateVA

VIII. Authorized Official

Name: MR. ANDY LEE EAGLE JR.
Title or Position: OWNER
Credential:
Phone: 434-736-8887