Basic Information
| Provider Information | |||||||||
| NPI: | 1013399849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ECCLES | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | RILEY | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3330 PEACH ST | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165082769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148775484 | ||||||||
| FaxNumber: | 8148775489 | ||||||||
| Practice Location | |||||||||
| Address1: | 3330 PEACH ST | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165082769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148775484 | ||||||||
| FaxNumber: | 8148775489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2015 | ||||||||
| LastUpdateDate: | 07/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DN005195 | PA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.