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General NPI Number Information
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NPI Number | 1275428484
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Entity Type | Organization
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Legal Business Name | MUDARIS HEALTHCARE LLC
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Dates
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Enumeration Date | 06/09/2025
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Last Update Date | 06/09/2025
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Provider Practice Location Address
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Address Line | 4590 VALLEY PKWY SE APT E
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City | SMYRNA
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State | GA
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Zip | 30082-4981
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Country | US
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Telephone | 646-420-3010
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Fax |
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Provider Business Mailing Address
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Address Line | 1300 RIDENOUR BLVD NW STE 100
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City | KENNESAW
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State | GA
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Zip | 30152-4528
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Country | US
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Telephone | 470-995-1258
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | ANDRE DERRICOTTE
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Credential |
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Telephone | 646-420-3010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State |
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