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General NPI Number Information
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NPI Number | 1366799801
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Entity Type | Organization
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Legal Business Name | NINEVEH OUTREACH
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Dates
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Enumeration Date | 08/14/2012
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Last Update Date | 08/14/2012
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Provider Practice Location Address
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Address Line | 1601 COFFEE RD
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City | MODESTO
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State | CA
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Zip | 95355-2801
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Country | US
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Telephone | 209-529-7346
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Fax | 209-529-7034
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Provider Business Mailing Address
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Address Line | PO BOX 578901
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City | MODESTO
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State | CA
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Zip | 95357-8901
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Country | US
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Telephone | 209-529-7346
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Fax | 209-529-7034
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. MANUEL L CANGA
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Credential | M.D.
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Telephone | 209-529-7346
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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 | 550001116
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License Number State | CA
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