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General NPI Number Information
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NPI Number | 1992301402
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Entity Type | Organization
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Legal Business Name | PROGRESSIVE MEDICAL CLINIC LLC
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Dates
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Enumeration Date | 12/09/2020
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Last Update Date | 02/19/2021
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Provider Practice Location Address
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Address Line | 2098 TERON TRCE STE 300
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City | DACULA
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State | GA
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Zip | 30019-1667
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Country | US
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Telephone | 770-614-4060
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Fax | 678-482-7788
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Provider Business Mailing Address
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Address Line | 2098 TERON TRCE STE 300
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City | DACULA
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State | GA
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Zip | 30019-1667
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Country | US
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Telephone | 770-614-4060
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Fax | 678-482-7788
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Authorized Official
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Title or Position | OWNER
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Name | BENJAMIN MITCHELL
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Credential |
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Telephone | 770-614-4060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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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 | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number |
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License Number State |
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