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General NPI Number Information
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NPI Number | 1699572958
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Entity Type | Organization
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Legal Business Name | MEN'S DIVISION PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 02/25/2025
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Last Update Date | 02/25/2025
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Provider Practice Location Address
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Address Line | 11511 FM 1960 STE 102
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City | HUFFMAN
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State | TX
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Zip | 77336-2710
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Country | US
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Telephone | 832-832-8570
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Fax | 346-299-7263
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Provider Business Mailing Address
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Address Line | 1514 LYNNVIEW DR
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City | HOUSTON
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State | TX
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Zip | 77055-3428
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Country | US
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Telephone | 281-900-0597
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Fax | 346-299-7263
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Authorized Official
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Title or Position | FNP-BC
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Name | MICHAEL ROACH
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Credential | PRESIDENT
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Telephone | 281-900-0597
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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