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General NPI Number Information
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NPI Number | 1194504498
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Entity Type | Individual
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Provider Name | MARCOS ELISEO CHACON VILLANUEVA
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Gender | Male
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Dates
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Enumeration Date | 09/26/2023
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Last Update Date | 11/17/2024
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Provider Practice Location Address
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Address Line | 851 S SUNSET AVE APT T220
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City | WEST COVINA
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State | CA
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Zip | 91790-5510
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Country | US
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Telephone | 323-712-1840
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Fax |
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Provider Business Mailing Address
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Address Line | 200 E ROWLAND ST # 237
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City | COVINA
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State | CA
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Zip | 91723-3146
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Country | US
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Telephone | 323-712-1840
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246RP1900X
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Taxonomy Name | Phlebotomy Technician
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License Number | 02271594
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License Number State | CA
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