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General NPI Number Information
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NPI Number | 1336856830
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Entity Type | Organization
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Legal Business Name | WELLNESS HEALTH MEDICAL PROVIDER, P.C.
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Dates
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Enumeration Date | 11/03/2022
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Last Update Date | 11/03/2022
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Provider Practice Location Address
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Address Line | 1 LAURA LN
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City | EAST NORTHPORT
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State | NY
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Zip | 11731-4700
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Country | US
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Telephone | 949-325-7001
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Fax |
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Provider Business Mailing Address
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Address Line | 17981 SKY PARK CIR, BLDG 39, STE BC
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City | IRVINE
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State | CA
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Zip | 92614-6309
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Country | US
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Telephone | 949-325-7001
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Fax | 949-309-2797
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Authorized Official
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Title or Position | VP OF LEGAL
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Name | MICHAEL BOSHARDY
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Credential |
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Telephone | 773-814-3028
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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