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General NPI Number Information
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NPI Number | 1164680823
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Entity Type | Organization
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Legal Business Name | MCCLOUD DBA UROLOGY CLINIC
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Dates
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Enumeration Date | 05/29/2008
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Last Update Date | 05/29/2008
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Provider Practice Location Address
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Address Line | 830 PINE ST
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City | MOUNT SHASTA
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State | CA
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Zip | 96067-2137
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Country | US
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Telephone | 530-926-3891
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Fax |
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Provider Business Mailing Address
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Address Line | 830 PINE ST
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City | MOUNT SHASTA
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State | CA
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Zip | 96067-2137
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Country | US
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Telephone | 530-926-3891
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Fax |
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Authorized Official
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Title or Position | ENROLLMENT
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Name | MRS. ROBIN M VELTKAMP
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Credential |
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Telephone | 231-924-0244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A21996
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License Number State | CA
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