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General NPI Number Information
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NPI Number | 1710962642
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Entity Type | Individual
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Provider Name | MR. WILLES TODD BRAXTON
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Gender | Male
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Dates
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Enumeration Date | 12/14/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 5201 LEE RD KAEHLER MEMORIAL MEDICAL CLINIC
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City | BUZZARDS BAY
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State | MA
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Zip | 02542-1313
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Country | US
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Telephone | 508-968-6578
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1766
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City | MASHPEE
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State | MA
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Zip | 02649-1766
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Country | US
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Telephone | 508-564-4814
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number | B1673135
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License Number State | CA
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