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General NPI Number Information
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NPI Number | 1194330340
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Entity Type | Organization
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Legal Business Name | GREEN MOUNTAIN MED CON, INC
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Dates
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Enumeration Date | 09/14/2020
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Last Update Date | 06/24/2025
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Provider Practice Location Address
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Address Line | 8175 NW 12TH ST STE 221
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City | DORAL
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State | FL
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Zip | 33126-1828
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Country | US
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Telephone | 786-580-4957
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Fax | 786-773-5259
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Provider Business Mailing Address
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Address Line | 7925 NW 12TH ST STE 325
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City | DORAL
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State | FL
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Zip | 33126-1846
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Country | US
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Telephone | 786-580-4957
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Fax | 786-773-5259
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Authorized Official
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Title or Position | PRESIDENT
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Name | CLAUDIA FUNDORA
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Credential |
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Telephone | 786-571-2788
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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