Provider Demographics
NPI:1639596927
Name:EAGLES NEST GROUP HOME, DBA
Entity Type:Organization
Organization Name:EAGLES NEST GROUP HOME, DBA
Other - Org Name:EAGLES NEST BOYS RESIDENTIAL AGENCY
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE-DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TED
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCCLURE
Authorized Official - Suffix:I
Authorized Official - Credentials:6025681441
Authorized Official - Phone:602-568-1441
Mailing Address - Street 1:1802 E DOBBINS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-8500
Mailing Address - Country:US
Mailing Address - Phone:602-568-1441
Mailing Address - Fax:602-268-4834
Practice Address - Street 1:1802 E DOBBINS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-8500
Practice Address - Country:US
Practice Address - Phone:602-568-1441
Practice Address - Fax:602-268-4834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCBH4442322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children