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General NPI Number Information
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NPI Number | 1710351598
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Entity Type | Organization
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Legal Business Name | EAGLE VILLAGE INC
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Dates
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Enumeration Date | 11/17/2015
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Last Update Date | 11/15/2022
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Provider Practice Location Address
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Address Line | 4507 170TH AVE
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City | HERSEY
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State | MI
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Zip | 49639-8785
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Country | US
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Telephone | 231-832-2234
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Fax |
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Provider Business Mailing Address
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Address Line | 4507 170TH AVE
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City | HERSEY
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State | MI
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Zip | 49639-8785
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CATHEY PRUDHOMME
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Credential |
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Telephone | 231-832-7259
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number |
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License Number State |
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