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General NPI Number Information
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NPI Number | 1891947248
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Entity Type | Organization
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Legal Business Name | EAGLE WINGS, LLC
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Dates
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Enumeration Date | 10/16/2008
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Last Update Date | 10/16/2008
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Provider Practice Location Address
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Address Line | 1020 LONG BLVD #5
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City | LANSING
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State | MI
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Zip | 48911-6896
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Country | US
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Telephone | 517-420-6123
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Fax |
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Provider Business Mailing Address
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Address Line | 1538 STONEY PT
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City | LANSING
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State | MI
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Zip | 48917-1450
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Country | US
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Telephone | 517-323-8395
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DAVID J BROCK
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Credential | ACSW
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Telephone | 517-420-6123
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 6301005177
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License Number State | MI
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