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General NPI Number Information
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NPI Number | 1841215530
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Entity Type | Organization
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Legal Business Name | MODESTO PRIMARY CARE
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Dates
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Enumeration Date | 07/13/2006
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Last Update Date | 08/06/2008
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Provider Practice Location Address
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Address Line | 2020 COFFEE RD STE J2
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City | MODESTO
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State | CA
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Zip | 95355-2416
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Country | US
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Telephone | 209-572-0191
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4398
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City | MODESTO
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State | CA
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Zip | 95352-4398
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Country | US
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Telephone | 209-575-4575
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MICHELLE WATTLE
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Credential |
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Telephone | 209-575-4575
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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 | A17110
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License Number State | CA
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