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General NPI Number Information
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NPI Number | 1831563261
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Entity Type | Organization
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Legal Business Name | EAST CLINIC LLC
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Dates
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Enumeration Date | 11/23/2015
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Last Update Date | 12/03/2015
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Provider Practice Location Address
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Address Line | 539 HARDEE ST
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City | DALLAS
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State | GA
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Zip | 30132-4711
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Country | US
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Telephone | 770-505-0531
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Fax | 770-485-0570
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Provider Business Mailing Address
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Address Line | 539 HARDEE ST
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City | DALLAS
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State | GA
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Zip | 30132-4711
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Country | US
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Telephone | 770-505-0531
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. MARY J EAST
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Credential | M.D.
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Telephone | 770-505-0531
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 63187
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License Number State | GA
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