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General NPI Number Information
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NPI Number | 1932500634
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Entity Type | Organization
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Legal Business Name | ESTERO RETINA
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Dates
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Enumeration Date | 09/12/2014
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Last Update Date | 09/12/2014
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Provider Practice Location Address
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Address Line | 9500 CORKSCREW PALMS CIR
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City | ESTERO
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State | FL
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Zip | 33928-3307
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Country | US
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Telephone | 321-222-3937
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Fax |
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Provider Business Mailing Address
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Address Line | 8951 BONITA BEACH RD SE STE 525-298
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City | BONITA SPRINGS
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State | FL
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Zip | 34135-4201
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Country | US
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Telephone | 321-222-3937
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. KARLA KELLAM
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Credential |
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Telephone | 904-713-2126
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | ME105560
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License Number State | FL
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