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General NPI Number Information
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NPI Number | 1659446409
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Entity Type | Organization
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Legal Business Name | PROVIDENT MEDICAL CENTER
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Dates
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Enumeration Date | 11/21/2006
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Last Update Date | 09/06/2023
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Provider Practice Location Address
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Address Line | 831 SR L THORNTON FWY
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City | DALLAS
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State | TX
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Zip | 75203-2905
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Country | US
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Telephone | 214-948-7783
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Fax | 214-948-7793
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Provider Business Mailing Address
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Address Line | 831 SR L THORNTON FWY
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City | DALLAS
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State | TX
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Zip | 75203-2905
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Country | US
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Telephone | 214-948-7783
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Fax | 214-948-7793
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Authorized Official
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Title or Position | OWNER ADMINISTRATOR
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Name | DR. RONALD JEFFREY WASHINGTON I
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Credential | M.D
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Telephone | 214-948-7783
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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 | E1172
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License Number State | TX
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