MEDICARE: EAGLE WINGS, LLC

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	104100000X	Social Worker	6301005177	MI

General Provider Information

NPI Number	:	1891947248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE WINGS, LLC

Provider Business Mailing Address
First Line	:	1538 STONEY PT
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48917-1450
Country	:	US
Telephone Number	:	517-323-8395
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 LONG BLVD
Second Line	:	#5
City	:	LANSING
State	:	MI
Zip	:	48911-6896
Country	:	US
Telephone Number	:	517-420-6123
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID J BROCK
Credential	:	ACSW
Telephone Number	:	517-420-6123

Provider Enumeration Date	:	10/16/2008
Last Update Date	:	10/16/2008

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