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General NPI Number Information
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NPI Number | 1134582018
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Entity Type | Organization
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Legal Business Name | BACKROAD HEALTH CARE INC
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Dates
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Enumeration Date | 03/30/2016
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Last Update Date | 03/18/2019
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Provider Practice Location Address
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Address Line | 211 S PERRINE AVE
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City | CENTRALIA
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State | IL
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Zip | 62801-3635
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Country | US
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Telephone | 618-419-0011
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Fax | 888-980-2931
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Provider Business Mailing Address
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Address Line | 314 S POPLAR ST UNIT 864
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City | CENTRALIA
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State | IL
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Zip | 62801-0848
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Country | US
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Telephone | 618-419-0011
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Fax | 888-960-2931
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Authorized Official
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Title or Position | FNP/OWNER
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Name | MR. PAUL S HAVRILKA III
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Credential | FNP
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Telephone | 618-419-0011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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