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General NPI Number Information
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NPI Number | 1003632522
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Entity Type | Organization
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Legal Business Name | MYSTI BLU MANAGEMENT GROUP, LLC
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Dates
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Enumeration Date | 11/30/2024
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Last Update Date | 11/30/2024
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Provider Practice Location Address
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Address Line | 2459 E HEBRON PKWY STE 130
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City | CARROLLTON
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State | TX
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Zip | 75010-4477
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Country | US
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Telephone | 972-522-9799
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Fax | 469-546-9723
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Provider Business Mailing Address
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Address Line | 2459 E HEBRON PKWY STE 130
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City | CARROLLTON
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State | TX
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Zip | 75010-4477
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Country | US
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Telephone | 972-522-9799
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Fax | 469-546-9723
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Authorized Official
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Title or Position | OWNER
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Name | JERRIA BERNESTINE
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Credential | FNP-C
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Telephone | 310-756-4829
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251F00000X
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Taxonomy Name | Home Infusion Agency
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License Number |
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License Number State |
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