Provider Demographics
NPI:1578765749
Name:WITH EAGLE'S WINGS
Entity Type:Organization
Organization Name:WITH EAGLE'S WINGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WAKEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:307-857-5940
Mailing Address - Street 1:PO BOX 197
Mailing Address - Street 2:
Mailing Address - City:ST STEPHENS
Mailing Address - State:WY
Mailing Address - Zip Code:82524-0197
Mailing Address - Country:US
Mailing Address - Phone:307-857-5940
Mailing Address - Fax:307-857-5932
Practice Address - Street 1:11 GREAT PLAIN ROAD
Practice Address - Street 2:
Practice Address - City:ARAPAHOE
Practice Address - State:WY
Practice Address - Zip Code:82524-0197
Practice Address - Country:US
Practice Address - Phone:307-857-5940
Practice Address - Fax:307-857-5932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY261QM0801X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder