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General NPI Number Information
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NPI Number | 1811789696
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Entity Type | Organization
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Legal Business Name | REVAMED CLEWISTON
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Dates
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Enumeration Date | 05/19/2025
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Last Update Date | 05/19/2025
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Provider Practice Location Address
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Address Line | 406 S DEANE DUFF AVE
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City | CLEWISTON
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State | FL
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Zip | 33440-3818
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Country | US
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Telephone | 863-983-5453
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Fax |
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Provider Business Mailing Address
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Address Line | 406 S DEANE DUFF AVE
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City | CLEWISTON
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State | FL
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Zip | 33440-3818
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Country | US
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Telephone | 863-983-5453
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. NATHALIE BASTIEN-MONTPEIROUS
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Credential | M.D.
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Telephone | 863-983-5453
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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