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General NPI Number Information
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NPI Number | 1679790604
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Entity Type | Organization
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Legal Business Name | ALLERGY CLINIC LLC
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 511 SW 10TH AVE SUITE 1301
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City | PORTLAND
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State | OR
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Zip | 97205-2732
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Country | US
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Telephone | 503-228-0155
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Fax | 503-226-8342
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Provider Business Mailing Address
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Address Line | 511 SW 10TH AVE SUITE 1301
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City | PORTLAND
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State | OR
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Zip | 97205-2732
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Country | US
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Telephone | 503-228-0155
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Fax | 503-226-8342
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARK THOMAS O'HOLLAREN
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Credential | M.D.
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Telephone | 503-228-0155
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207KA0200X
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Taxonomy Name | Allergy Physician
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License Number | 13450
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License Number State | OR
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