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General NPI Number Information
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NPI Number | 1104471085
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Entity Type | Individual
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Provider Name | KELLEN J PINO MS, LAT, ATC, CES
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Gender | Male
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Dates
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Enumeration Date | 08/07/2019
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Last Update Date | 08/07/2019
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Provider Practice Location Address
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Address Line | 12200 LOMAS BLVD NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87112-5804
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Country | US
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Telephone | 505-559-2200
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Fax |
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Provider Business Mailing Address
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Address Line | 4500 SHADOW AVE NW
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City | ALBUQUERQUE
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State | NM
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Zip | 87114-5063
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Country | US
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Telephone | 505-681-0748
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083S0010X
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Taxonomy Name | Sports Medicine (Preventive Medicine) Physician
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License Number | 424
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License Number State | NM
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