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General NPI Number Information
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NPI Number | 1568650935
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Entity Type | Individual
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Provider Name | PRAMOD BHANTI PT
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Gender | Male
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Dates
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Enumeration Date | 10/10/2007
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Last Update Date | 10/12/2007
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Provider Practice Location Address
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Address Line | 5 UNION AVE OM PROFESSIONAL CENTER SUITE 1
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City | CENTER MORICHES
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State | NY
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Zip | 11934-3323
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Country | US
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Telephone | 631-878-1771
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Fax | 631-878-3319
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Provider Business Mailing Address
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Address Line | 1 LOUIS AVE P.O. BOX 577
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City | MORICHES
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State | NY
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Zip | 11955-1403
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Country | US
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Telephone | 631-878-1771
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Fax | 631-878-3319
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 86691
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License Number State | NY
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