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General NPI Number Information
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NPI Number | 1710213236
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Entity Type | Organization
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Legal Business Name | CD EAST FAMILY HEALTH & WELLNESS CENTER LLC
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Dates
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Enumeration Date | 10/19/2009
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Last Update Date | 05/26/2010
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Provider Practice Location Address
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Address Line | 845 SIR THOMAS CT SUITE 5
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City | HARRISBURG
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State | PA
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Zip | 17109-4840
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Country | US
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Telephone | 717-695-3704
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Fax | 717-695-7735
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Provider Business Mailing Address
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Address Line | 845 SIR THOMAS CT SUITE 5
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City | HARRISBURG
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State | PA
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Zip | 17109-4840
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Country | US
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Telephone | 717-695-3704
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Fax | 717-695-7735
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. ANGELIQUE MCKINNEY-BOURNE
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Credential | M.D.
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Telephone | 717-695-3704
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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 | MD418042
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License Number State | PA
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