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General NPI Number Information
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NPI Number | 1245631126
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Entity Type | Organization
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Legal Business Name | BONA VITA WELLNESS AND PSYCHIATRIC CENTER
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Dates
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Enumeration Date | 09/10/2014
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Last Update Date | 02/25/2019
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Provider Practice Location Address
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Address Line | 117B RIVER ST
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City | MILFORD
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State | CT
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Zip | 06460
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Country | US
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Telephone | 203-283-3515
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Fax | 203-518-8008
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Provider Business Mailing Address
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Address Line | 117B RIVER ST
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City | MILFORD
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State | CT
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Zip | 06460-3315
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Country | US
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Telephone | 203-283-3515
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Fax | 203-518-8008
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Authorized Official
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Title or Position | CEO
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Name | DR. PAVLE JOKSOVIC
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Credential | MD
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Telephone | 203-283-3515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 048935
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License Number State | CT
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