Provider Demographics
NPI:1043888688
Name:ECLIPSE PSYCHIATRY
Entity Type:Organization
Organization Name:ECLIPSE PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMANI
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:978-697-0301
Mailing Address - Street 1:2152 S VINEYARD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6871
Mailing Address - Country:US
Mailing Address - Phone:978-697-0301
Mailing Address - Fax:
Practice Address - Street 1:2152 S VINEYARD UNIT 113-114
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6871
Practice Address - Country:US
Practice Address - Phone:623-282-2047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-10
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1295370401Medicaid