Provider Demographics
NPI:1669014767
Name:EAGLES, FREDRICK LEE
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:LEE
Last Name:EAGLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E WOODHURST DR STE Q100
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4240
Mailing Address - Country:US
Mailing Address - Phone:417-877-1300
Mailing Address - Fax:
Practice Address - Street 1:1200 E WOODHURST DR STE Q100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4240
Practice Address - Country:US
Practice Address - Phone:417-877-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2472E0500X
MO2002017980225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG