MEDICARE: EAGLE RIDGE ACADEMY

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	:	1831467331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE RIDGE ACADEMY

Provider Business Mailing Address
First Line	:	7255 FLYING CLOUD DRIVE
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344
Country	:	US
Telephone Number	:	952-746-7760
Fax Number	:

Provider Business Practice Location Address
First Line	:	7255 FLYING CLOUD DRIVE
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344
Country	:	US
Telephone Number	:	952-746-7760
Fax Number	:

Authorized Official
Title or Position	:	SPECIAL EDUCATION COORDINATOR
Name	:	MRS. MELISSA GAIL UDOMAH
Credential	:	MA
Telephone Number	:	952-746-7760

Provider Enumeration Date	:	12/12/2011
Last Update Date	:	12/12/2011

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