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General NPI Number Information
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NPI Number | 1710706874
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Entity Type | Organization
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Legal Business Name | SOUTH LA EYE CLINIC
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Dates
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Enumeration Date | 10/07/2024
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Last Update Date | 10/07/2024
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Provider Practice Location Address
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Address Line | 231 W VERNON AVE STE 104
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City | LOS ANGELES
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State | CA
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Zip | 90037-2778
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Country | US
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Telephone | 323-233-6271
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Fax | 323-233-8196
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Provider Business Mailing Address
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Address Line | 646 W MAIN ST
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City | EL CENTRO
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State | CA
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Zip | 92243-7914
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Country | US
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Telephone | 760-996-3507
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Fax | 442-271-4337
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MR. LUIS MALDONADO
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Credential |
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Telephone | 760-996-3507
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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