Provider Demographics
NPI:1518124957
Name:EAGLE MEDICAL MANAGEMENT, INC.
Entity Type:Organization
Organization Name:EAGLE MEDICAL MANAGEMENT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:WOODYARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-427-4438
Mailing Address - Street 1:10252 SE US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34420-6819
Mailing Address - Country:US
Mailing Address - Phone:352-245-7245
Mailing Address - Fax:352-245-6317
Practice Address - Street 1:10252 SE US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-6819
Practice Address - Country:US
Practice Address - Phone:352-245-7245
Practice Address - Fax:352-245-6317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL679680096251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL679680096Medicaid
FL679680098Medicaid