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General NPI Number Information
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NPI Number | 1760429641
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Entity Type | Organization
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Legal Business Name | VALLEY ALLERGY AND ASTHMA CLINIC PLLC
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Dates
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Enumeration Date | 06/01/2006
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Last Update Date | 01/03/2020
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Provider Practice Location Address
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Address Line | 5757 W THUNDERBIRD RD W205
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City | GLENDALE
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State | AZ
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Zip | 85306-4641
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Country | US
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Telephone | 602-548-0981
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5148
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City | GLENDALE
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State | AZ
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Zip | 85312-5148
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | PRAVEENA R KOTHUR
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Credential | MD
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Telephone | 602-548-0981
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 30666
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License Number State | AZ
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