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General NPI Number Information
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NPI Number | 1932608916
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Entity Type | Organization
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Legal Business Name | PIONEER HEALING AND RESTORATION SERVICES INC,
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Dates
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Enumeration Date | 02/06/2018
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Last Update Date | 02/06/2018
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Provider Practice Location Address
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Address Line | 1885 UNIVERSITY AVE W STE 300A
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City | SAINT PAUL
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State | MN
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Zip | 55104-3462
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Country | US
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Telephone | 612-564-9554
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Fax |
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Provider Business Mailing Address
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Address Line | 1885 UNIVERSITY AVE W, SUITE 300A
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City | ST PAUL
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State | MN
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Zip | 55104
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Country | US
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Telephone | 612-564-9554
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | OMAR MOHAMED
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Credential |
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Telephone | 612-636-3593
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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