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General NPI Number Information
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NPI Number | 1518340124
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Entity Type | Organization
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Legal Business Name | MED LAKE CENTER LLC
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Dates
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Enumeration Date | 06/30/2015
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Last Update Date | 10/13/2015
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Provider Practice Location Address
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Address Line | 16371 NW 67TH AVE
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City | MIAMI LAKES
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State | FL
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Zip | 33014-6044
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Country | US
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Telephone | 786-332-4991
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Fax | 786-409-2037
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Provider Business Mailing Address
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Address Line | 16371 NW 67TH AVE
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City | MIAMI LAKES
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State | FL
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Zip | 33014-6044
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Country | US
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Telephone | 786-332-4991
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Fax | 786-409-6203
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MRS. MAYRA LOURDES ZENO
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Credential | MD
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Telephone | 786-332-4991
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | HCC11818
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License Number State | FL
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