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General NPI Number Information
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NPI Number | 1154478766
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Entity Type | Organization
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Legal Business Name | PRIMARY CARE WEST, S.C.
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Dates
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Enumeration Date | 01/04/2007
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Last Update Date | 02/03/2011
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Provider Practice Location Address
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Address Line | 1300 N HIGHLAND AVE SUITE 2
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City | AURORA
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State | IL
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Zip | 60506-1451
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Country | US
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Telephone | 630-897-9606
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Fax | 630-897-9625
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Provider Business Mailing Address
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Address Line | 1300 N HIGHLAND AVE SUITE 2
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City | AURORA
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State | IL
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Zip | 60506-1451
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Country | US
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Telephone | 630-897-9606
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Fax | 630-897-9625
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Authorized Official
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Title or Position | PRESIDENT
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Name | DAVE MANTE
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Credential | M.D.
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Telephone | 630-897-9606
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 042617613
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License Number State | IL
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