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General NPI Number Information
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NPI Number | 1811273642
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Entity Type | Organization
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Legal Business Name | PREMIUM ASSISTED CARE
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Dates
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Enumeration Date | 10/25/2011
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Last Update Date | 10/25/2011
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Provider Practice Location Address
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Address Line | 549 HILLCREST DR
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City | GARLAND
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State | TX
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Zip | 75040-5618
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Country | US
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Telephone | 214-808-6070
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Fax |
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Provider Business Mailing Address
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Address Line | 333 LOMA ALTA DR
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City | MESQUITE
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State | TX
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Zip | 75150-3185
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Country | US
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Telephone | 214-808-6070
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Fax |
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Authorized Official
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Title or Position | PROGRAM MANAGER (OWNER)
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Name | MRS. DORIS MAE GORDON
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Credential |
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Telephone | 214-808-6070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State |
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