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General NPI Number Information
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NPI Number | 1770722936
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Entity Type | Organization
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Legal Business Name | MEDICAL AND WELLNESS CENTER OF MELROSE CORPORATION
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Dates
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Enumeration Date | 02/11/2009
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Last Update Date | 07/16/2014
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Provider Practice Location Address
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Address Line | 1745 SR 100
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City | MELROSE
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State | FL
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Zip | 32666
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Country | US
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Telephone | 954-854-4290
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Fax |
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Provider Business Mailing Address
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Address Line | 1745 SR 100
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City | MELROSE
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State | FL
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Zip | 32666
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Country | US
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Telephone | 352-478-2471
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Fax | 352-478-2496
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | MS. KENYETTA LATRICE REESE
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Credential |
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Telephone | 352-478-2471
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | ARNP780412
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ACN205
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License Number State | FL
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