Provider Demographics
NPI:1710551585
Name:ECLIPSE CLINIC PLLC
Entity Type:Organization
Organization Name:ECLIPSE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-526-4604
Mailing Address - Street 1:1006 LEGACY RANCH RD
Mailing Address - Street 2:104
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165
Mailing Address - Country:US
Mailing Address - Phone:817-826-4604
Mailing Address - Fax:
Practice Address - Street 1:1006 LEGACY RANCH RD
Practice Address - Street 2:104
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165
Practice Address - Country:US
Practice Address - Phone:817-826-4604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15016694OtherCAQH