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General NPI Number Information
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NPI Number | 1477290096
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Entity Type | Organization
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Legal Business Name | MMD PROFESSIONAL SERVICES CORP
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Dates
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Enumeration Date | 05/16/2022
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Last Update Date | 05/16/2022
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Provider Practice Location Address
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Address Line | 1680 SW BAYSHORE BOULEVARD SUITE 100
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City | PORT ST. LUCIE
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State | FL
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Zip | 34984
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Country | US
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Telephone | 786-715-7072
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Fax |
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Provider Business Mailing Address
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Address Line | 13311 GRANGER AVE
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City | ORLANDO
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State | FL
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Zip | 32827-3857
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Country | US
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Telephone | 786-715-7072
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Fax |
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Authorized Official
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Title or Position | BCBA
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Name | MIGUEL H GARCIA PEDRAJA
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Credential |
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Telephone | 786-715-7072
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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 |
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License Number State |
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