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General NPI Number Information
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NPI Number | 1962710293
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Entity Type | Organization
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Legal Business Name | TIMOTHY R PORT OD INC-CA
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Dates
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Enumeration Date | 09/21/2010
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Last Update Date | 08/23/2011
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Provider Practice Location Address
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Address Line | 110 N SPRING ST
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City | BLYTHE
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State | CA
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Zip | 92225-1633
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Country | US
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Telephone | 760-922-3951
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Fax | 760-922-5202
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Provider Business Mailing Address
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Address Line | 110 N SPRING ST
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City | BLYTHE
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State | CA
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Zip | 92225-1633
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Country | US
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Telephone | 760-922-3951
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Fax | 760-922-5202
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TIMOTHY REEVE PORT
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Credential | O.D.
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Telephone | 760-922-3951
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | CPT 5925
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License Number State | CA
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