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General NPI Number Information
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NPI Number | 1669725941
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Entity Type | Organization
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Legal Business Name | REDICLINIC
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Dates
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Enumeration Date | 10/23/2012
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Last Update Date | 05/13/2014
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Provider Practice Location Address
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Address Line | 701 W PARKWOOD AVE
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City | FRIENDSWOOD
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State | TX
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Zip | 77546-5405
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Country | US
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Telephone | 281-947-0018
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Fax |
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Provider Business Mailing Address
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Address Line | 2801 VENETO CT
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City | LEAGUE CITY
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State | TX
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Zip | 77573-5006
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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 | FAMILY NURSE PRACTITIONER
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Name | MICA MALEIGH WYNN VELA
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Credential | NP-C
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Telephone | 832-632-2170
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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 | 717330
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License Number State | TX
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