Provider Demographics
NPI:1659492429
Name:EAGLE CREST LIFE SERVICES, INC.
Entity Type:Organization
Organization Name:EAGLE CREST LIFE SERVICES, INC.
Other - Org Name:ECLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:208-666-9162
Mailing Address - Street 1:PO BOX 3723
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-2529
Mailing Address - Country:US
Mailing Address - Phone:208-666-9162
Mailing Address - Fax:208-769-9321
Practice Address - Street 1:212 S 11TH ST
Practice Address - Street 2:STE. 3
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4000
Practice Address - Country:US
Practice Address - Phone:208-666-9162
Practice Address - Fax:208-769-9321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID807602900251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807602900Medicaid