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General NPI Number Information
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NPI Number | 1023524980
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Entity Type | Organization
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Legal Business Name | ST. JOHNS URGENT CARE & MEDICAL CORPORATION
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Dates
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Enumeration Date | 12/14/2017
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Last Update Date | 12/20/2017
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Provider Practice Location Address
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Address Line | 1138 N WESTERN AVE
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City | LOS ANGELES
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State | CA
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Zip | 90029-1702
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Country | US
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Telephone | 323-957-9300
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Fax | 323-957-9315
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Provider Business Mailing Address
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Address Line | 1138 NORTH WESTERN AVE
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City | LOS ANGELES
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State | CA
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Zip | 90029-1702
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Country | US
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Telephone | 323-957-9300
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Fax | 323-957-9315
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Authorized Official
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Title or Position | MEDICAL DIRECTOR/ OWNER
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Name | MIKE MANSOUR ROSTAMI
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Credential | M.D
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Telephone | 323-957-9300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | A50108
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License Number State | CA
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