MEDICARE: DESERT SOARING EAGLE

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1962103986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT SOARING EAGLE

Provider Business Mailing Address
First Line	:	1348 BELVIDERE ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-1831
Country	:	US
Telephone Number	:	575-502-4241
Fax Number	:

Provider Business Practice Location Address
First Line	:	1348 BELVIDERE ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-1831
Country	:	US
Telephone Number	:	575-502-4241
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	PATRICK J RYAN
Credential	:	LCSW
Telephone Number	:	575-502-4241

Provider Enumeration Date	:	03/16/2023
Last Update Date	:	03/16/2023

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