Provider Demographics
NPI:1659630127
Name:EICHLINE, ERIC ALLEN (LPN)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:ALLEN
Last Name:EICHLINE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N9402 HWY X
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N9402 COUNTY ROAD X
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9462
Practice Address - Country:US
Practice Address - Phone:608-981-2045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI313582164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse