MEDICARE: EAGLE ADVANTAGE ACADEMY, INC.

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)	057806	TX

General Provider Information

NPI Number	:	1659517829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE ADVANTAGE ACADEMY, INC.

Provider Business Mailing Address
First Line	:	4011 JOSEPH HARDIN DR STE F
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75236-1507
Country	:	US
Telephone Number	:	214-276-5846
Fax Number	:	214-467-4499

Provider Business Practice Location Address
First Line	:	4011 JOSEPH HARDIN DR STE F
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75236-1507
Country	:	US
Telephone Number	:	214-276-5846
Fax Number	:	214-467-4499

Authorized Official
Title or Position	:	CEO/SUPERINDENTANT
Name	:	DR. ALLEN BECK
Credential	:	PHD
Telephone Number	:	214-276-5800

Provider Enumeration Date	:	12/18/2008
Last Update Date	:	12/18/2008

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