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General NPI Number Information
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NPI Number | 1639398613
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Entity Type | Organization
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Legal Business Name | SHADOWRIDGE MEDICAL GROUP
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Dates
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Enumeration Date | 04/25/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1680 S MELROSE DR STE 105
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City | VISTA
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State | CA
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Zip | 92081-5472
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Country | US
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Telephone | 760-727-6920
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Fax | 760-727-3368
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Provider Business Mailing Address
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Address Line | 1680 S MELROSE DR STE 105
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City | VISTA
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State | CA
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Zip | 92081-5472
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Country | US
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Telephone | 760-727-6920
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Fax | 760-727-3368
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Authorized Official
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Title or Position | PHYSICIAN
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Name | TODD WINE
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Credential | M.D.
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Telephone | 760-727-6920
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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 | G045531
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License Number State | CA
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