Provider Demographics
NPI:1710351598
Name:EAGLE VILLAGE INC
Entity Type:Organization
Organization Name:EAGLE VILLAGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CATHEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUDHOMME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-832-7259
Mailing Address - Street 1:4507 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:HERSEY
Mailing Address - State:MI
Mailing Address - Zip Code:49639-8785
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4507 170TH AVE
Practice Address - Street 2:
Practice Address - City:HERSEY
Practice Address - State:MI
Practice Address - Zip Code:49639-8785
Practice Address - Country:US
Practice Address - Phone:231-832-2234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility