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General NPI Number Information
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NPI Number | 1689382020
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Entity Type | Individual
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Provider Name | SAMUEL ELIJAH LUPKES OD
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Gender | Male
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Dates
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Enumeration Date | 11/14/2022
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Last Update Date | 11/14/2022
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Provider Practice Location Address
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Address Line | 300 WESTERN AVE NW STE 100 1/2
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City | FARIBAULT
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State | MN
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Zip | 55021-4528
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Country | US
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Telephone | 916-747-0029
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Fax |
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Provider Business Mailing Address
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Address Line | 601 1ST AVE NE APT 327
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City | FARIBAULT
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State | MN
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Zip | 55021-2904
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Country | US
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Telephone | 916-747-0029
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3832
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License Number State | MN
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