=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588923775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KHANH LE EAGLE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2012
-----------------------------------------------------
Last Update Date | 05/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9601 HOLLY POINT DR
-----------------------------------------------------
City | HUNTERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28078-4910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-987-8446
-----------------------------------------------------
Fax | 704-987-9292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9601 HOLLY POINT DR
-----------------------------------------------------
City | HUNTERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28078-4910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-987-8446
-----------------------------------------------------
Fax | 704-987-9292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 200000780
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------