Provider Demographics
NPI:1053809574
Name:AEGLE GROUP LLC
Entity type:Organization
Organization Name:AEGLE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MACLAREN
Authorized Official - Suffix:
Authorized Official - Credentials:MHHA
Authorized Official - Phone:850-250-5757
Mailing Address - Street 1:3003 S HIGHWAY 77 STE F
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-5627
Mailing Address - Country:US
Mailing Address - Phone:850-250-5757
Mailing Address - Fax:
Practice Address - Street 1:3003 S HIGHWAY 77 STE F
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-5627
Practice Address - Country:US
Practice Address - Phone:850-250-5757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-30
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL710189Medicaid