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General NPI Number Information
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NPI Number | 1912261231
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Entity Type | Organization
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Legal Business Name | SUPREME TEAM LLC
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Dates
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Enumeration Date | 07/02/2012
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Last Update Date | 07/02/2012
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Provider Practice Location Address
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Address Line | 1520 12TH ST
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City | AUGUSTA
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State | GA
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Zip | 30901-3676
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Country | US
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Telephone | 706-364-4710
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Fax |
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Provider Business Mailing Address
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Address Line | 5327 WINDMILL PKWY
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City | EVANS
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State | GA
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Zip | 30809-6651
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Country | US
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Telephone | 706-951-7514
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. CALETHA TAYLOR
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Credential |
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Telephone | 706-951-7514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number |
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License Number State | GA
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