MEDICARE: ECLIPSE MEDICAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1497207872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ECLIPSE MEDICAL LLC

Provider Business Mailing Address
First Line	:	1660 W ANTELOPE DR
Second Line	:	STE 320
City	:	LAYTON
State	:	UT
Zip	:	84041-1156
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1660 W ANTELOPE DR
Second Line	:	STE 320
City	:	LAYTON
State	:	UT
Zip	:	84041-1156
Country	:	US
Telephone Number	:	801-376-0227
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRENT BINGHAM
Credential	:
Telephone Number	:	801-376-0227

Provider Enumeration Date	:	11/01/2016
Last Update Date	:	11/01/2016

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