Healthcare Provider Details

I. General information

NPI: 1598023285
Provider Name (Legal Business Name): ECCLES MEDICAL, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 W MAIN ST SUITE 3
BOONEVILLE AR
72927-3642
US

IV. Provider business mailing address

67 W MAIN ST SUITE 3
BOONEVILLE AR
72927-3642
US

V. Phone/Fax

Practice location:
  • Phone: 479-675-3300
  • Fax: 479-675-3301
Mailing address:
  • Phone: 479-675-3300
  • Fax: 479-675-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-7083
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-7083
License Number StateAR

VIII. Authorized Official

Name: MRS. TERESA ECCLES
Title or Position: OFFICE MANAGER
Credential:
Phone: 479-675-3300