Provider Demographics
NPI:1891947248
Name:EAGLE WINGS, LLC
Entity Type:Organization
Organization Name:EAGLE WINGS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:ACSW
Authorized Official - Phone:517-420-6123
Mailing Address - Street 1:1538 STONEY PT
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-1450
Mailing Address - Country:US
Mailing Address - Phone:517-323-8395
Mailing Address - Fax:
Practice Address - Street 1:1020 LONG BLVD
Practice Address - Street 2:#5
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-6896
Practice Address - Country:US
Practice Address - Phone:517-420-6123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005177104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty