Healthcare Provider Details

I. General information

NPI: 1518500446
Provider Name (Legal Business Name): JOHN STEVEN ECCLES PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MARK WEST SPRINGS RD
SANTA ROSA CA
95403-1766
US

IV. Provider business mailing address

34 MARK WEST SPRINGS RD STE 300
SANTA ROSA CA
95403-1783
US

V. Phone/Fax

Practice location:
  • Phone: 707-522-5401
  • Fax:
Mailing address:
  • Phone: 707-522-5401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT18050
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: