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General NPI Number Information
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NPI Number | 1033437132
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Entity Type | Organization
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Legal Business Name | NINAK INC.
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Dates
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Enumeration Date | 05/13/2010
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Last Update Date | 05/13/2010
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Provider Practice Location Address
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Address Line | 170 E BROADWAY
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City | JACKSON
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State | WY
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Zip | 82001-9906
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Country | US
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Telephone | 307-203-9239
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Fax |
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Provider Business Mailing Address
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Address Line | 23371 MULHOLLAND DR STE 327
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City | WOODLAND HILLS
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State | CA
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Zip | 91364-2734
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Country | US
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Telephone | 307-203-9239
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Fax | 877-332-9683
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Authorized Official
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Title or Position | FAMILY PRACTICE
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Name | MR. MICHAEL JOHN LEE
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Credential | M.D.,
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Telephone | 307-203-9239
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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 | 6084A
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License Number State | WY
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