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General NPI Number Information
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NPI Number | 1962600171
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Entity Type | Organization
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Legal Business Name | CLINICA FAMILIAR BELLA VISTA
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Dates
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Enumeration Date | 07/10/2007
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Last Update Date | 07/15/2015
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Provider Practice Location Address
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Address Line | 515 W BUCKEYE RD STE 303
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City | PHOENIX
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State | AZ
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Zip | 85003-2647
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Country | US
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Telephone | 602-423-8956
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 10176
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City | GLENDALE
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State | AZ
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Zip | 85318-0176
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Country | US
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Telephone | 602-423-8961
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. WILL INNOCENT
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Credential | M.D
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Telephone | 602-423-8961
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 32113
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License Number State | AZ
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