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General NPI Number Information
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NPI Number | 1851561716
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Entity Type | Organization
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Legal Business Name | MAYO RETINA, INC.
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Dates
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Enumeration Date | 03/07/2008
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Last Update Date | 03/07/2008
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Provider Practice Location Address
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Address Line | 16543 BROOKHURST ST
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City | FOUNTAIN VALLEY
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State | CA
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Zip | 92708-2343
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Country | US
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Telephone | 714-475-8612
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Fax |
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Provider Business Mailing Address
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Address Line | 322 12TH ST
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92648-4519
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Country | US
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Telephone | 714-475-8612
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KATHERINE MAYO
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Credential | D.O.
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Telephone | 714-475-8612
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 20A9551
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 261QS0132X
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Taxonomy Name | Ophthalmologic Surgery Clinic/Center
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License Number | G83501
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License Number State | CA
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