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General NPI Number Information
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NPI Number | 1508021858
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Entity Type | Organization
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Legal Business Name | FASTVAX LLC
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Dates
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Enumeration Date | 07/25/2008
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Last Update Date | 01/17/2011
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Provider Practice Location Address
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Address Line | 1500 HORIZON DR ST 120
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City | CHALFONT
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State | PA
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Zip | 18914-3966
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Country | US
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Telephone | 267-308-0534
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Fax | 267-308-0533
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Provider Business Mailing Address
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Address Line | 1500 HORIZON DR SUITE 120
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City | CHALFONT
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State | PA
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Zip | 18914-3966
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Country | US
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Telephone | 215-996-1400
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Fax | 267-308-0533
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Authorized Official
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Title or Position | CEO
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Name | MR. SIEVERT LARSSON
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Credential |
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Telephone | 215-996-1400
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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 | MD061592L
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License Number State | PA
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