Healthcare Provider Details

I. General information

NPI: 1811412570
Provider Name (Legal Business Name): EAGLE ACQUISITION XII LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W CONSTANCE RD
SUFFOLK VA
23434-4413
US

IV. Provider business mailing address

200 W CONSTANCE RD
SUFFOLK VA
23434-4413
US

V. Phone/Fax

Practice location:
  • Phone: 757-539-8744
  • Fax: 747-539-6128
Mailing address:
  • Phone: 757-539-8744
  • Fax: 747-539-6128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: BENT PHILIPSON
Title or Position: MANAGING MEMBER
Credential:
Phone: 516-869-3700