Provider Demographics
NPI:1386984375
Name:M8D2RISE EAGLES PROGRAM, INC
Entity type:Organization
Organization Name:M8D2RISE EAGLES PROGRAM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-907-7268
Mailing Address - Street 1:2302 W MEADOWVIEW RD
Mailing Address - Street 2:SUITE 124 MOREHEAD BLDG.
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-3721
Mailing Address - Country:US
Mailing Address - Phone:336-907-7268
Mailing Address - Fax:336-707-7311
Practice Address - Street 1:2302 W MEADOWVIEW RD
Practice Address - Street 2:SUITE 124 MOREHEAD BLDG.
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3721
Practice Address - Country:US
Practice Address - Phone:336-907-7268
Practice Address - Fax:336-707-7311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC281050302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization