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General NPI Number Information
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NPI Number | 1467194696
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Entity Type | Organization
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Legal Business Name | BLUE MOON MEDICAL CENTER INC
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Dates
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Enumeration Date | 04/08/2022
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Last Update Date | 08/18/2022
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Provider Practice Location Address
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Address Line | 7715 NW 48TH ST STE 360B
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City | DORAL
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State | FL
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Zip | 33166-5455
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Country | US
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Telephone | 786-300-9963
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Fax | 852-036-6553
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Provider Business Mailing Address
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Address Line | 7715 NW 48TH ST STE 360B
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City | DORAL
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State | FL
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Zip | 33166-5455
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Country | US
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Telephone | 786-300-9963
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Fax | 852-036-6553
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Authorized Official
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Title or Position | OWNER
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Name | YARIANA SANCHEZ
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Credential |
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Telephone | 786-300-9963
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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