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General NPI Number Information
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NPI Number | 1215960091
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Entity Type | Organization
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Legal Business Name | FULL CARE MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 07/08/2006
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Last Update Date | 12/19/2012
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Provider Practice Location Address
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Address Line | 3903 LONE TREE WAY SUITE 104
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City | ANTIOCH
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State | CA
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Zip | 94509-6249
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Country | US
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Telephone | 925-755-1255
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Fax | 925-755-1259
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Provider Business Mailing Address
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Address Line | 3903 LONE TREE WAY SUITE 104
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City | ANTIOCH
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State | CA
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Zip | 94509-6249
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Country | US
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Telephone | 925-755-1255
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Fax | 925-755-1259
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Authorized Official
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Title or Position | CFO BUSINESS MANAGER
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Name | TERRI A KHONSARI
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Credential |
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Telephone | 925-755-1255
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 48607
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License Number State | CA
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