Healthcare Provider Details

I. General information

NPI: 1295259356
Provider Name (Legal Business Name): MS. MAKAYLA ROSE ECCLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 07/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5740 RALSTON ST STE 100
VENTURA CA
93003-7847
US

IV. Provider business mailing address

120 FRENCHYS CV APT 87
CAMARILLO CA
93012-9172
US

V. Phone/Fax

Practice location:
  • Phone: 805-289-3100
  • Fax:
Mailing address:
  • Phone: 805-914-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: