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General NPI Number Information
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NPI Number | 1194241380
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Entity Type | Organization
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Legal Business Name | PRO ORTHO PHYSICAL THERAPY PLLC
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Dates
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Enumeration Date | 08/18/2017
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Last Update Date | 01/25/2018
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Provider Practice Location Address
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Address Line | 2240 E CENTER ST
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City | POCATELLO
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State | ID
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Zip | 83201-2600
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Country | US
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Telephone | 208-478-6780
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Fax | 208-478-0194
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Provider Business Mailing Address
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Address Line | 2240 E CENTER ST
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City | POCATELLO
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State | ID
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Zip | 83201-2600
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Country | US
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Telephone | 208-478-6780
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Fax | 208-478-0194
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Authorized Official
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Title or Position | OWNER
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Name | ROBERT LANCE MARSHALL
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Credential | DPT
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Telephone | 208-478-6780
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | PT1003
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License Number State | ID
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