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General NPI Number Information
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NPI Number | 1710422746
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Entity Type | Organization
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Legal Business Name | DIRECTCLINIC LLC
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Dates
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Enumeration Date | 12/29/2016
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Last Update Date | 12/29/2016
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Provider Practice Location Address
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Address Line | 7802 W JEFFERSON BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46804-4138
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Country | US
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Telephone | 260-466-5671
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Fax |
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Provider Business Mailing Address
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Address Line | 6435 W JEFFERSON BLVD SUITE 176
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City | FORT WAYNE
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State | IN
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Zip | 46804-6203
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Country | US
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Telephone | 260-212-1900
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Fax |
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Authorized Official
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Title or Position | PRESIDENT & CEO
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Name | MR. SUDHAKAR KRISHNAN
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Credential |
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Telephone | 260-212-1900
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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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