Provider Demographics
NPI:1275539819
Name:ECKERT, CHARLES LESLIE (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LESLIE
Last Name:ECKERT
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 1:1298A W FOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-8303
Mailing Address - Country:US
Mailing Address - Phone:816-322-2057
Mailing Address - Fax:816-322-3156
Practice Address - Street 1:1296B W FOXWOOD DR
Practice Address - Street 2:
Practice Address - City:RAYMORE
Practice Address - State:MO
Practice Address - Zip Code:64083-8300
Practice Address - Country:US
Practice Address - Phone:816-322-2057
Practice Address - Fax:816-322-3156
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5051111NI0900X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0007108Medicare ID - Type Unspecified
MOT73845Medicare UPIN