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General NPI Number Information
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NPI Number | 1629807086
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Entity Type | Organization
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Legal Business Name | ATLAS MEDICAL ACO LLC
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Dates
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Enumeration Date | 08/01/2024
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Last Update Date | 10/17/2024
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Provider Practice Location Address
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Address Line | 3831 E BLUE LUPINE DR STE C
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City | WASILLA
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State | AK
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Zip | 99654-8461
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Country | US
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Telephone | 907-521-2368
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4682
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City | LOGAN
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State | UT
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Zip | 84323-4682
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GREGORY CHAD MANGUM
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Credential |
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Telephone | 435-514-5646
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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 |
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License Number State |
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