MEDICARE: EAGLE COLLEGE PREP ENDEAVOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1477099117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE COLLEGE PREP ENDEAVOR

Provider Business Mailing Address
First Line	:	2617 SHENANDOAH AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-2311
Country	:	US
Telephone Number	:	314-450-7651
Fax Number	:	314-735-4471

Provider Business Practice Location Address
First Line	:	2617 SHENANDOAH AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-2311
Country	:	US
Telephone Number	:	314-450-7651
Fax Number	:	314-735-4471

Authorized Official
Title or Position	:	REGIONAL DIRECTOR OF OPERATIONS
Name	:	MRS. DANA SHEARMAN
Credential	:
Telephone Number	:	314-503-2239

Provider Enumeration Date	:	01/18/2017
Last Update Date	:	01/18/2017

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