Provider Demographics
NPI:1700051711
Name:EAGLE DANCER INC
Entity Type:Organization
Organization Name:EAGLE DANCER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:STIDD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:812-330-0909
Mailing Address - Street 1:414 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-1513
Mailing Address - Country:US
Mailing Address - Phone:812-331-1962
Mailing Address - Fax:812-332-1949
Practice Address - Street 1:414 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-1513
Practice Address - Country:US
Practice Address - Phone:812-331-1962
Practice Address - Fax:812-332-1949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN280-B332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5410560001Medicare NSC