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General NPI Number Information
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NPI Number | 1114110574
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Entity Type | Organization
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Legal Business Name | PRIMARY EYECARE
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Dates
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Enumeration Date | 08/20/2007
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Last Update Date | 01/03/2008
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Provider Practice Location Address
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Address Line | 627 S HOUSTON LAKE RD SUITE 100
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City | WARNER ROBINS
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State | GA
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Zip | 31088-9077
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Country | US
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Telephone | 478-322-0009
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Fax |
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Provider Business Mailing Address
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Address Line | 3801 NORTHSDIE DR
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City | MACON
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State | GA
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Zip | 31201
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Country | US
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Telephone | 478-475-1600
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Fax | 478-475-4160
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Authorized Official
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Title or Position | BLLING MANAGER
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Name | LETA M BIRD
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Credential |
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Telephone | 478-475-1600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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