Healthcare Provider Details

I. General information

NPI: 1053438531
Provider Name (Legal Business Name): JOLENE KELLY ECCLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2677 ZOE AVE STE 304
HUNTINGTON PARK CA
90255-3699
US

IV. Provider business mailing address

506 W JACKMAN ST
LANCASTER CA
93534-2531
US

V. Phone/Fax

Practice location:
  • Phone: 323-346-0960
  • Fax:
Mailing address:
  • Phone: 661-726-2850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: