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General NPI Number Information
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NPI Number | 1528749041
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Entity Type | Organization
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Legal Business Name | TRIAD COMPLETE HEALTHCARE A10 LLC
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Dates
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Enumeration Date | 07/27/2023
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Last Update Date | 02/05/2024
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Provider Practice Location Address
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Address Line | 4151 N HARRISON
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City | SHAWNEE
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State | OK
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Zip | 74804
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Country | US
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Telephone | 405-613-9720
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Fax |
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Provider Business Mailing Address
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Address Line | 20228 RED OAK CT
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City | TECUMSEH
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State | OK
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Zip | 74873-7131
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Country | US
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Telephone | 405-613-9720
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | ERIC WINEGARDNER
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Credential |
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Telephone | 405-613-9720
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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 |
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License Number State |
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