Healthcare Provider Details

I. General information

NPI: 1013399849
Provider Name (Legal Business Name): KIMBERLY RILEY ECCLES RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 07/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 PEACH ST SUITE 211
ERIE PA
16508-2769
US

IV. Provider business mailing address

3330 PEACH ST SUITE 211
ERIE PA
16508-2769
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-5484
  • Fax: 814-877-5489
Mailing address:
  • Phone: 814-877-5484
  • Fax: 814-877-5489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN005195
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: