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General NPI Number Information
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NPI Number | 1104957612
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Entity Type | Organization
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Legal Business Name | EYE CLINIC OF SANDPOINT PA
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Dates
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Enumeration Date | 03/08/2007
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Last Update Date | 02/15/2018
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Provider Practice Location Address
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Address Line | 307 S 1ST AVE
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City | SANDPOINT
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State | ID
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Zip | 83864-1201
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Country | US
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Telephone | 208-263-8501
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Fax |
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Provider Business Mailing Address
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Address Line | 307 S 1ST AVE
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City | SANDPOINT
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State | ID
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Zip | 83864-1201
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Country | US
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Telephone | 208-263-8501
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN-OWNER
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Name | DR. JASON M PETERSEN
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Credential | DO
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Telephone | 208-263-8501
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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