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General NPI Number Information
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NPI Number | 1144694480
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Entity Type | Organization
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Legal Business Name | REGENERATIVE WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 11/24/2015
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Last Update Date | 11/24/2015
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Provider Practice Location Address
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Address Line | 8633 MEXICO RD
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City | O FALLON
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State | MO
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Zip | 63366-7506
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Country | US
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Telephone | 636-272-8888
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Fax | 636-272-7385
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Provider Business Mailing Address
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Address Line | 8633 MEXICO RD
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City | O FALLON
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State | MO
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Zip | 63366-7506
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Country | US
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Telephone | 636-272-8888
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Fax | 636-272-7385
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | MICHAEL WILLIAMS
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Credential |
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Telephone | 636-272-8891
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2009009432
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License Number State | MO
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