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General NPI Number Information
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NPI Number | 1770576134
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Entity Type | Individual
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Provider Name | BRENT J. VAN ANDEL M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/31/2005
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Last Update Date | 07/01/2013
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Provider Practice Location Address
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Address Line | 711 BOND ST EL CENTRO FAMILY HEALTH BOND CLINIC
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City | ESPANOLA
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State | NM
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Zip | 87532-2729
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Country | US
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Telephone | 505-753-9503
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Fax | 505-747-1004
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Provider Business Mailing Address
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Address Line | PO BOX 158 EL CENTRO FAMILY HEALTH
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City | ESPANOLA
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State | NM
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Zip | 87532-0158
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Country | US
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Telephone | 505-753-7218
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Fax | 505-753-5815
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2004-0159
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License Number State | NM
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