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General NPI Number Information
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NPI Number | 1326773045
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Entity Type | Organization
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Legal Business Name | PROVIDENCE FAMILY LIFE CENTER CORPORATION
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Dates
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Enumeration Date | 07/18/2022
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Last Update Date | 07/18/2022
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Provider Practice Location Address
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Address Line | 3592 BROADWAY STE 100
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City | FORT MYERS
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State | FL
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Zip | 33901-8056
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Country | US
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Telephone | 239-676-3159
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Fax | 239-519-9202
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Provider Business Mailing Address
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Address Line | 3049 CLEVELAND AVE
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City | FORT MYERS
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State | FL
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Zip | 33901-7041
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Country | US
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Telephone | 239-676-3159
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Fax | 888-519-9202
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Authorized Official
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Title or Position | BILLING SPECIALIST
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Name | LAURA KOHLER
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Credential |
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Telephone | 813-720-7694
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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