Provider Demographics
NPI:1174601447
Name:EAGLE'S TRACE INC
Entity type:Organization
Organization Name:EAGLE'S TRACE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-402-2315
Mailing Address - Street 1:14703 EAGLE VISTA DRIVE
Mailing Address - Street 2:ATTN: EXECUTIVE DIRECTOR
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-5394
Mailing Address - Country:US
Mailing Address - Phone:281-249-7000
Mailing Address - Fax:410-204-7237
Practice Address - Street 1:14703 EAGLE VISTA DRIVE
Practice Address - Street 2:ATTN: REHABILITATION MGR
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-5394
Practice Address - Country:US
Practice Address - Phone:281-249-7000
Practice Address - Fax:410-204-7237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX660930000261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676658Medicare Oscar/Certification