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General NPI Number Information
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NPI Number | 1861732190
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Entity Type | Organization
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Legal Business Name | FOMUKONG HEALTH FOUNDATION INC
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Dates
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Enumeration Date | 02/23/2013
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Last Update Date | 02/23/2013
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Provider Practice Location Address
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Address Line | 2355 WESTWOOD BLVD # 332
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City | LOS ANGELES
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State | CA
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Zip | 90064-2109
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Country | US
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Telephone | 310-701-6703
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Fax |
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Provider Business Mailing Address
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Address Line | 2355 WESTWOOD BLVD # 332
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City | LOS ANGELES
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State | CA
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Zip | 90064-2109
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Country | US
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Telephone | 310-701-6703
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MR. NDIKA FOMUKONG
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Credential | FNP/PAC
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Telephone | 310-701-6703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 2768722
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License Number State | CA
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