Healthcare Provider Details

I. General information

NPI: 1952689945
Provider Name (Legal Business Name): TERRY M. ECCLES, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72-LL WEST STAFFORD ROAD
STAFFORD SPRINGS CT
06076
US

IV. Provider business mailing address

72-LL WEST STAFFORD ROAD
STAFFORD SPRINGS CT
06076
US

V. Phone/Fax

Practice location:
  • Phone: 860-684-5015
  • Fax: 860-684-3749
Mailing address:
  • Phone: 860-684-5015
  • Fax: 860-684-3749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number037680
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number005863
License Number StateCT

VIII. Authorized Official

Name: DR. TERRY M. ECCLES
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 860-684-5015