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General NPI Number Information
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NPI Number | 1073737391
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Entity Type | Organization
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Legal Business Name | ACTIVE CARE MEDICAL ASSOCIATES OF CONYERS, LLC
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1229 SALEM GATE DRIVE
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City | CONYERS
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State | GA
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Zip | 30013
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Country | US
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Telephone | 770-761-2302
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Fax | 770-761-2303
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Provider Business Mailing Address
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Address Line | PMB#359 1040 HONEY CREEK ROAD
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City | CONYERS
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State | GA
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Zip | 30013
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Country | US
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Telephone | 770-761-2302
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Fax | 770-761-2303
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | MR. STEVEN T. WILDER
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Credential | DC
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Telephone | 770-761-2302
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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