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General NPI Number Information
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NPI Number | 1184991127
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Entity Type | Organization
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Legal Business Name | RADIANT HEALTH CHIROPRACTIC LLC
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Dates
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Enumeration Date | 11/18/2011
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Last Update Date | 08/23/2021
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Provider Practice Location Address
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Address Line | 209 DUNLAWTON AVE STE 18
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City | PORT ORANGE
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State | FL
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Zip | 32127-4458
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Country | US
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Telephone | 386-308-9076
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Fax | 386-675-6591
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Provider Business Mailing Address
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Address Line | 209 DUNLAWTON AVE STE 18
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City | PORT ORANGE
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State | FL
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Zip | 32127-4458
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Country | US
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Telephone | 386-308-9076
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Fax | 386-675-6591
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | BRANDON LAVELLE
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Credential | D.C.
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Telephone | 386-308-9076
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH9993
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License Number State | FL
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