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General NPI Number Information
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NPI Number | 1164893178
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Entity Type | Organization
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Legal Business Name | WHITE CLOVER, LLC
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Dates
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Enumeration Date | 10/16/2015
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Last Update Date | 01/26/2016
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Provider Practice Location Address
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Address Line | 460 ASHLEY RIDGE BLVD STE 600
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City | SHREVEPORT
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State | LA
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Zip | 71106-7235
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Country | US
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Telephone | 318-861-4226
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Fax |
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Provider Business Mailing Address
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Address Line | 460 ASHLEY RIDGE BLVD STE 600
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City | SHREVEPORT
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State | LA
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Zip | 71106-7235
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Country | US
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Telephone | 318-861-4226
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | MRS. TAMARA M SMITH
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Credential |
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Telephone | 318-455-8856
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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