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General NPI Number Information
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NPI Number | 1184718132
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Entity Type | Organization
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Legal Business Name | MID STATE ARTIFICIAL LIMB CO, INC
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 11/09/2010
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Provider Practice Location Address
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Address Line | 4455 MEDGAR EVERS BLVD
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City | JACKSON
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State | MS
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Zip | 39213-5202
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Country | US
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Telephone | 601-981-2229
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Fax | 601-362-2129
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Provider Business Mailing Address
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Address Line | PO BOX 31092
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City | JACKSON
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State | MS
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Zip | 39286-1092
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Country | US
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Telephone | 601-981-2229
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Fax | 601-362-2129
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Authorized Official
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Title or Position | PRESIDENT
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Name | TROY LUSTER
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Credential |
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Telephone | 601-981-2229
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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