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General NPI Number Information
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NPI Number | 1609201235
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Entity Type | Organization
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Legal Business Name | PREMIUM CHOICE CARE LLC
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Dates
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Enumeration Date | 09/13/2013
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Last Update Date | 11/12/2019
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Provider Practice Location Address
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Address Line | 1983 GENEVA AVE N STE 1983
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City | OAKDALE
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State | MN
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Zip | 55128-4108
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Country | US
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Telephone | 651-239-6149
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Fax | 651-772-3357
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Provider Business Mailing Address
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Address Line | 1949 GENEVA AVE N STE 1983
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City | OAKDALE
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State | MN
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Zip | 55128-4108
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Country | US
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Telephone | 651-239-6149
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Fax | 651-772-3357
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Authorized Official
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Title or Position | MANAGER
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Name | MR. FERDINAND MBAANIK FONDO
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Credential |
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Telephone | 651-239-6149
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 698669300020
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License Number State | MN
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