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General NPI Number Information
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NPI Number | 1164655767
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Entity Type | Organization
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Legal Business Name | UNIVERSITY CLINIC
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Dates
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Enumeration Date | 08/29/2009
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Last Update Date | 08/29/2009
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Provider Practice Location Address
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Address Line | 2535 UNIVERSITY BLVD W
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City | JACKSONVILLE
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State | FL
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Zip | 32217-2003
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Country | US
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Telephone | 904-367-8686
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 56164
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City | JACKSONVILLE
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State | FL
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Zip | 32241-6164
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Country | US
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Telephone | 904-367-8686
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | CARMEN DAMASCO
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Credential |
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Telephone | 904-367-8686
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 06776
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License Number State | FL
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