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General NPI Number Information
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NPI Number | 1114140019
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Entity Type | Organization
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Legal Business Name | KOKOPELLI EYE CARE PC
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Dates
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Enumeration Date | 04/10/2007
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Last Update Date | 11/16/2007
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Provider Practice Location Address
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Address Line | 412 WHIPPLE ST
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City | PRESCOTT
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State | AZ
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Zip | 86301-1712
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Country | US
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Telephone | 928-771-9000
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Fax | 928-771-9460
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Provider Business Mailing Address
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Address Line | 2820 N GLASSFORD HILL RD SUITE 101
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-1242
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Country | US
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Telephone | 928-775-5606
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Fax | 928-772-4999
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MICHAEL L HAM
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Credential | MD
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Telephone | 928-771-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | OSC3634
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License Number State | AZ
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