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General NPI Number Information
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NPI Number | 1003907676
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Entity Type | Organization
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Legal Business Name | TWIN STATES FAMILY CARE CENTER
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Dates
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Enumeration Date | 09/27/2006
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | HIGHWAY 102
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City | WOLFE
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State | WV
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Zip | 24751
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Country | US
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Telephone | 304-248-8096
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Fax | 304-248-8096
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Provider Business Mailing Address
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Address Line | PO BOX 19
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City | NEMOURS
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State | WV
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Zip | 24738-0019
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Country | US
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Telephone | 304-248-8096
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Fax | 304-248-8096
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Authorized Official
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Title or Position | OWNER
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Name | REYNALDO JOSE
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Credential | MD
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Telephone | 304-248-8096
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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 | 11738WV
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License Number State | WV
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