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General NPI Number Information
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NPI Number | 1104118884
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Entity Type | Organization
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Legal Business Name | SUPAM LLC
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Dates
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Enumeration Date | 05/12/2011
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Last Update Date | 03/01/2012
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Provider Practice Location Address
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Address Line | 5419 NORTH LOVINGTON HIGHWAY SUITE 7
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City | HOBBS
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State | NM
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Zip | 88240-9135
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Country | US
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Telephone | 575-392-3903
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Fax | 575-392-3911
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Provider Business Mailing Address
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Address Line | 5419 N LOVINGTON HWY SUITE 7
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City | HOBBS
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State | NM
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Zip | 88240-9100
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Country | US
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Telephone | 575-392-3903
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Fax | 575-392-3911
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Authorized Official
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Title or Position | OWNER
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Name | MUKESHBHAI B PATEL
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Credential | MD
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Telephone | 732-713-2824
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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