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General NPI Number Information
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NPI Number | 1972970341
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Entity Type | Organization
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Legal Business Name | PROVIDER LABORATORY SERVICES LLC
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Dates
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Enumeration Date | 09/01/2015
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Last Update Date | 01/10/2017
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Provider Practice Location Address
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Address Line | 88 OXFORD ST
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City | LEWISTON
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State | ME
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Zip | 04240-7825
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Country | US
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Telephone | 207-241-7722
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Fax | 207-312-5677
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Provider Business Mailing Address
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Address Line | PO BOX 1150 306 RODMAN ROAD
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City | AUBURN
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State | ME
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Zip | 04211-1150
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Country | US
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Telephone | 207-333-3278
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Fax | 207-333-3037
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Authorized Official
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Title or Position | GENERAL PARTNER
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Name | MR. TOM VURGASON
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Credential |
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Telephone | 207-333-3278
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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