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General NPI Number Information
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NPI Number | 1518983360
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Entity Type | Organization
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Legal Business Name | SHAMROCK FAMILY PRACTICE LLC
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Dates
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Enumeration Date | 07/14/2006
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Last Update Date | 09/21/2009
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Provider Practice Location Address
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Address Line | 2000 CLARK ST
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City | MILES CITY
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State | MT
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Zip | 59301-2726
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Country | US
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Telephone | 406-234-3824
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Fax | 406-234-1041
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Provider Business Mailing Address
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Address Line | PO BOX 579
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City | MILES CITY
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State | MT
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Zip | 59301-0579
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Country | US
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Telephone | 406-234-3824
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Fax | 406-234-1041
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | CATHIE S HENNEBERRY
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Credential | ENP
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Telephone | 406-234-8863
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4771
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | RN26836
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License Number State | MT
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