Provider Demographics
NPI:1376613869
Name:ECLECTIC FAMILY CARE, LLC
Entity type:Organization
Organization Name:ECLECTIC FAMILY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCCULLOCH
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:334-541-3020
Mailing Address - Street 1:PO BOX 241120
Mailing Address - Street 2:
Mailing Address - City:ECLECTIC
Mailing Address - State:AL
Mailing Address - Zip Code:36024-0018
Mailing Address - Country:US
Mailing Address - Phone:334-541-3020
Mailing Address - Fax:334-541-3109
Practice Address - Street 1:575 CLAUD RD
Practice Address - Street 2:
Practice Address - City:ECLECTIC
Practice Address - State:AL
Practice Address - Zip Code:36024-6318
Practice Address - Country:US
Practice Address - Phone:334-541-3020
Practice Address - Fax:334-541-3109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12809174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL99530Medicaid
AL99530Medicaid