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General NPI Number Information
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NPI Number | 1588736276
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Entity Type | Organization
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Legal Business Name | HERITAGE CLINIC S.C.
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 201 N MAYFAIR RD SUITE 535
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City | WAUWATOSA
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State | WI
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Zip | 53226-4216
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Country | US
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Telephone | 414-771-6020
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Fax | 414-771-2242
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Provider Business Mailing Address
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Address Line | 9449 N BROADMOOR RD
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City | BAYSIDE
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State | WI
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Zip | 53217-1310
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Country | US
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Telephone | 414-771-6020
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Fax | 414-771-2242
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RAYMOND PAUL MAGER
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Credential | D.O.
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Telephone | 414-771-6020
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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 | 19290
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License Number State | WI
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