Provider Demographics
NPI:1215436548
Name:EAGLE ONE MEDICAL, INC.
Entity type:Organization
Organization Name:EAGLE ONE MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-647-7150
Mailing Address - Street 1:644 CESERY BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-7165
Mailing Address - Country:US
Mailing Address - Phone:904-647-7150
Mailing Address - Fax:904-551-2462
Practice Address - Street 1:644 CESERY BLVD STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-7165
Practice Address - Country:US
Practice Address - Phone:904-647-7150
Practice Address - Fax:904-551-2462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies