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General NPI Number Information
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NPI Number | 1457395568
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Entity Type | Organization
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Legal Business Name | PROVIDACARE MEDICAL SUPPLY LTD
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Dates
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Enumeration Date | 06/16/2006
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Last Update Date | 05/19/2023
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Provider Practice Location Address
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Address Line | 8303 N MOPAC EXPY STE A215
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City | AUSTIN
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State | TX
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Zip | 78759-8751
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Country | US
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Telephone | 512-733-6500
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Fax | 512-733-6511
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Provider Business Mailing Address
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Address Line | PO BOX 27010
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City | AUSTIN
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State | TX
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Zip | 78755-2010
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Country | US
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Telephone | 512-733-6500
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Fax | 512-733-6511
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Authorized Official
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Title or Position | CEO
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Name | MR. RYAN N BENNETT
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Credential |
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Telephone | 512-733-6518
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BX2000X
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Taxonomy Name | Oxygen Equipment & Supplies (DME)
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License Number | 0089310
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License Number State | TX
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