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General NPI Number Information
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NPI Number | 1659492429
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Entity Type | Organization
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Legal Business Name | EAGLE CREST LIFE SERVICES, INC.
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Dates
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Enumeration Date | 04/02/2007
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Last Update Date | 03/13/2009
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Provider Practice Location Address
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Address Line | 212 S 11TH ST STE. 3
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City | COEUR D ALENE
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State | ID
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Zip | 83814-4000
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Country | US
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Telephone | 208-666-9162
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Fax | 208-769-9321
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Provider Business Mailing Address
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Address Line | PO BOX 3723
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City | COEUR D ALENE
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State | ID
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Zip | 83816-2529
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Country | US
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Telephone | 208-666-9162
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Fax | 208-769-9321
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. ROBERT WHEELER
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Credential | BA
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Telephone | 208-666-9162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 807602900
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License Number State | ID
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