=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598023285
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ECCLES MEDICAL, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2012
-----------------------------------------------------
Last Update Date | 07/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 67 W MAIN ST SUITE 3
-----------------------------------------------------
City | BOONEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72927-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-675-3300
-----------------------------------------------------
Fax | 479-675-3301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 67 W MAIN ST SUITE 3
-----------------------------------------------------
City | BOONEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72927-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-675-3300
-----------------------------------------------------
Fax | 479-675-3301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. TERESA ECCLES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-675-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | E-7083
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | E-7083
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------