Provider Demographics
NPI:1245992262
Name:ECLIPSE WELLNESS LLC
Entity type:Organization
Organization Name:ECLIPSE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKANISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-919-1607
Mailing Address - Street 1:623 W NEWPORT PIKE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804-3235
Mailing Address - Country:US
Mailing Address - Phone:302-777-5473
Mailing Address - Fax:
Practice Address - Street 1:623 W NEWPORT PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19804-3235
Practice Address - Country:US
Practice Address - Phone:302-777-5473
Practice Address - Fax:302-777-5483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-07
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE250694990Medicaid