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General NPI Number Information
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NPI Number | 1750015616
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Entity Type | Organization
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Legal Business Name | BLUE LINE MEDICAL CORP
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Dates
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Enumeration Date | 07/14/2022
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Last Update Date | 07/14/2022
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Provider Practice Location Address
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Address Line | 3120 WILLOW AVE STE 101
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City | CLOVIS
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State | CA
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Zip | 93612-4714
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Country | US
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Telephone | 559-370-8694
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Fax | 626-377-4221
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Provider Business Mailing Address
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Address Line | 1099 E. CHAMPLAIN DRIVE SUITE A #186
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City | FRESNO
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State | CA
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Zip | 93720
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Country | US
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Telephone | 559-370-8694
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Fax | 626-377-4221
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. LEO L FONG
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Credential | MD
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Telephone | 559-370-8694
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number |
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License Number State |
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