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General NPI Number Information
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NPI Number | 1093990210
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Entity Type | Organization
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Legal Business Name | THE ROSE CLINIC FOR PLASTIC AND MIGRAINE SURGERY
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Dates
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Enumeration Date | 01/07/2008
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Last Update Date | 06/13/2008
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Provider Practice Location Address
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Address Line | 320 RIVER PARK DR SUITE 245
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City | PROVO
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State | UT
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Zip | 84604-6060
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Country | US
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Telephone | 801-375-7673
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Fax | 801-375-7679
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Provider Business Mailing Address
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Address Line | 320 RIVER PARK DR SUITE245
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City | PROVO
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State | UT
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Zip | 84604-6060
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Country | US
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Telephone | 801-375-7673
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Fax | 801-375-7679
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | DR. KEVIN G ROSE
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Credential | M.D.
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Telephone | 801-375-7673
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 5575028-1205
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License Number State | UT
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