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General NPI Number Information
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NPI Number | 1447244959
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Entity Type | Organization
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Legal Business Name | SUNRISE CLINICAL LABORATORY
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Dates
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Enumeration Date | 09/12/2005
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Last Update Date | 10/22/2007
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Provider Practice Location Address
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Address Line | 21216 OLEAN BLVD 3
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952-6722
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Country | US
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Telephone | 941-624-3005
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Fax | 941-624-6405
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Provider Business Mailing Address
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Address Line | 21216 OLEAN BLVD 3
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952-6722
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Country | US
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Telephone | 941-624-3005
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Fax | 941-624-6405
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Authorized Official
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Title or Position | OWNER
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Name | MR. MIFTAH KEMAL
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Credential | M.S.
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Telephone | 941-624-3005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State | FL
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