1710551585 NPI number — ECLIPSE CLINIC PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710551585 NPI number — ECLIPSE CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ECLIPSE CLINIC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710551585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1006 LEGACY RANCH RD
Provider Second Line Business Mailing Address:
104
Provider Business Mailing Address City Name:
WAXAHACHIE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-826-4604
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1006 LEGACY RANCH RD
Provider Second Line Business Practice Location Address:
104
Provider Business Practice Location Address City Name:
WAXAHACHIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-826-4604
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/17/2021

Additional Information

Authorized Official

Authorized Official Last Name:
LEEK
Authorized Official First Name:
DUSTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
817-526-4604

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 15016694 . This is a "CAQH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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