Provider Demographics
NPI:1184338774
Name:GLORIOUS EAGLES LLC
Entity type:Organization
Organization Name:GLORIOUS EAGLES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:PROF
Authorized Official - First Name:SAMSON
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAYANDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-456-6090
Mailing Address - Street 1:2119 110TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4173
Mailing Address - Country:US
Mailing Address - Phone:612-456-6090
Mailing Address - Fax:
Practice Address - Street 1:2119 110TH LN NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4173
Practice Address - Country:US
Practice Address - Phone:612-456-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-09
Last Update Date:2023-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No385H00000XRespite Care FacilityRespite Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services