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General NPI Number Information
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NPI Number | 1275157000
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Entity Type | Organization
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Legal Business Name | PROVIDENT HEALTH PARTNERS INC.
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Dates
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Enumeration Date | 06/08/2020
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Last Update Date | 06/08/2020
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Provider Practice Location Address
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Address Line | 1529 N OCEAN AVE STE A
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City | MEDFORD
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State | NY
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Zip | 11763-3587
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Country | US
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Telephone | 631-266-4501
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Fax | 631-266-4502
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Provider Business Mailing Address
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Address Line | 554 LARKFIELD RD STE 207
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City | EAST NORTHPORT
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State | NY
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Zip | 11731-4205
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Country | US
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Telephone | 631-266-4501
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Fax | 631-266-4502
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JENNIFER DESOUSA
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Credential |
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Telephone | 631-266-4501
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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