Provider Demographics
NPI:1336894393
Name:EAGLE EYE GROUP HOME, INC.
Entity Type:Organization
Organization Name:EAGLE EYE GROUP HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:ANNMARIE
Authorized Official - Last Name:ANNIKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAID PROVIDER
Authorized Official - Phone:321-978-6509
Mailing Address - Street 1:415 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-4432
Mailing Address - Country:US
Mailing Address - Phone:863-547-4886
Mailing Address - Fax:863-547-4993
Practice Address - Street 1:415 EAGLE EYE GROUP HOME, INC
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759
Practice Address - Country:US
Practice Address - Phone:863-547-4886
Practice Address - Fax:863-547-4993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692345396Medicaid