Provider Demographics
NPI:1578725057
Name:EAGLEWOOD VILLAGE, LTD.
Entity Type:Organization
Organization Name:EAGLEWOOD VILLAGE, LTD.
Other - Org Name:EAGLEWOOD VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:V
Authorized Official - Last Name:GULLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-863-4640
Mailing Address - Street 1:3001 MIDDLE URBANA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-9284
Mailing Address - Country:US
Mailing Address - Phone:937-399-7009
Mailing Address - Fax:937-390-8253
Practice Address - Street 1:3001 MIDDLE URBANA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-9284
Practice Address - Country:US
Practice Address - Phone:937-399-7009
Practice Address - Fax:937-390-8253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1998R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility