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General NPI Number Information
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NPI Number | 1700332285
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Entity Type | Organization
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Legal Business Name | MINIMALLY INVASIVE THERAPIES A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 08/25/2016
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Last Update Date | 08/25/2016
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Provider Practice Location Address
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Address Line | 18400 US HIGHWAY 18 SUITE A
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City | APPLE VALLEY
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State | CA
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Zip | 92307-2306
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Country | US
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Telephone | 760-242-3939
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Fax | 760-810-7593
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Provider Business Mailing Address
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Address Line | 11202 LINDSAY LN
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City | APPLE VALLEY
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State | CA
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Zip | 92308-3637
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Country | US
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Telephone | 660-349-0020
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. SAMUEL SHIN KWON LEE
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Credential | M.D.
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Telephone | 660-349-0020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | A49819
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License Number State | CA
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