Provider Demographics
NPI:1104182864
Name:MOUNT EAGLES WINGS INC
Entity Type:Organization
Organization Name:MOUNT EAGLES WINGS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VENNA
Authorized Official - Middle Name:SHARELL
Authorized Official - Last Name:REESE
Authorized Official - Suffix:
Authorized Official - Credentials:HEATHCARE PROVIDER
Authorized Official - Phone:706-284-9959
Mailing Address - Street 1:4027 PRESCOTT DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-4308
Mailing Address - Country:US
Mailing Address - Phone:706-284-9959
Mailing Address - Fax:
Practice Address - Street 1:4027 PRESCOTT DR
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-4308
Practice Address - Country:US
Practice Address - Phone:706-284-9959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-07
Last Update Date:2012-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities