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General NPI Number Information
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NPI Number | 1043765753
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Entity Type | Organization
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Legal Business Name | NEUROLOGY RESTORATION CENTER LLC
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Dates
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Enumeration Date | 08/23/2016
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Last Update Date | 10/02/2017
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Provider Practice Location Address
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Address Line | 1701 SE HILLMOOR DR SUITE D-16
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34952-7552
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Country | US
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Telephone | 772-201-1162
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7938
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34985-7938
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Country | US
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Telephone | 772-210-1162
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Fax |
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Authorized Official
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Title or Position | OWNER/MD
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Name | MS. LUZ G VAZQUEZ
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Credential | MD
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Telephone | 772-210-1162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | ME68140
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License Number State | FL
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