Provider Demographics
NPI:1639485667
Name:EAGLEMERELIVINGFACILITY
Entity Type:Organization
Organization Name:EAGLEMERELIVINGFACILITY
Other - Org Name:NA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:JR
Authorized Official - Credentials:NA
Authorized Official - Phone:252-907-4805
Mailing Address - Street 1:200 EAGLES MERE TRL
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-8850
Mailing Address - Country:US
Mailing Address - Phone:252-442-4209
Mailing Address - Fax:
Practice Address - Street 1:200 EAGLES MERE TRL
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-8850
Practice Address - Country:US
Practice Address - Phone:252-442-4209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health