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General NPI Number Information
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NPI Number | 1770734659
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Entity Type | Organization
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Legal Business Name | EYE ASSOCIATES OF SEBASTOPOL MEDICAL GROUP
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Dates
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Enumeration Date | 10/09/2008
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Last Update Date | 10/09/2008
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Provider Practice Location Address
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Address Line | 14709 LAKESHORE DRIVE
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City | CLEARLAKE
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State | CA
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Zip | 95422-5539
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Country | US
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Telephone | 707-994-8644
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Fax | 707-994-5015
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Provider Business Mailing Address
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Address Line | PO BOX 5539
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City | CLEARLAKE
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State | CA
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Zip | 95422-5539
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Country | US
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Telephone | 707-994-8644
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Fax | 707-994-5015
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Authorized Official
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Title or Position | OWNER
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Name | DR. ERIC J KAHLE
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Credential | MD
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Telephone | 707-823-7628
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 97-518945 00004 JH
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License Number State | CA
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