Provider Demographics
NPI:1700914900
Name:ECKLEY, PAUL (DC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:ECKLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2352 S COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2128
Mailing Address - Country:US
Mailing Address - Phone:248-960-0520
Mailing Address - Fax:248-438-5463
Practice Address - Street 1:2352 S COMMERCE RD
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-2128
Practice Address - Country:US
Practice Address - Phone:248-960-0520
Practice Address - Fax:248-438-5463
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005305111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950F369000OtherBCBS
MI950F369000OtherBCBS
MIP22400002Medicare ID - Type Unspecified
T34538Medicare UPIN