Provider Demographics
NPI:1013304211
Name:EAGLE RISING HEALTH SERVICES, PLLC
Entity Type:Organization
Organization Name:EAGLE RISING HEALTH SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:HARP
Authorized Official - Suffix:JR
Authorized Official - Credentials:PA
Authorized Official - Phone:704-334-6370
Mailing Address - Street 1:1008 CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1535
Mailing Address - Country:US
Mailing Address - Phone:704-334-6370
Mailing Address - Fax:
Practice Address - Street 1:8815 UNIVERSITY EAST DR STE 215
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-4100
Practice Address - Country:US
Practice Address - Phone:980-318-3602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-25
Last Update Date:2015-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101599261QH0100X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service