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General NPI Number Information
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NPI Number | 1457667784
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Entity Type | Organization
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Legal Business Name | VEIN CLINIC PA
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Dates
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Enumeration Date | 08/24/2010
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Last Update Date | 01/02/2013
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Provider Practice Location Address
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Address Line | 16372 KENRICK AVE SUITE 100
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City | LAKEVILLE
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State | MN
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Zip | 55044-3540
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Country | US
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Telephone | 952-892-1222
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Fax | 952-892-1221
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Provider Business Mailing Address
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Address Line | 470 W 78TH ST STE. 250
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City | CHANHASSEN
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State | MN
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Zip | 55317-4524
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Country | US
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Telephone | 952-934-3296
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Fax | 952-906-1737
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | DR. SAMEER GUPTA
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Credential | MD
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Telephone | 952-934-3296
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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