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General NPI Number Information
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NPI Number | 1821486358
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Entity Type | Organization
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Legal Business Name | GRACE SOUTHERN MEDICAL CLINIC, PLLC
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Dates
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Enumeration Date | 01/07/2015
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Last Update Date | 01/07/2015
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Provider Practice Location Address
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Address Line | 6300 SAMUELL BLVD STE. 120
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City | DALLAS
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State | TX
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Zip | 75228-7137
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Country | US
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Telephone | 214-381-1910
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Fax | 214-381-2868
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Provider Business Mailing Address
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Address Line | 6300 SAMUELL BLVD STE. 120
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City | DALLAS
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State | TX
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Zip | 75228-7137
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Country | US
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Telephone | 214-381-1910
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Fax | 214-381-2868
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Authorized Official
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Title or Position | MEMBER
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Name | SERGIO CALIXTO-MONTANEZ
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Credential | M.D.
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Telephone | 214-381-1910
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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 | P4031
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License Number State | TX
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