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General NPI Number Information
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NPI Number | 1205352127
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Entity Type | Organization
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Legal Business Name | SOUTHERN PROSTHETIC CARE LLC
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Dates
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Enumeration Date | 08/22/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 4201 HIGHWAY 11 N STE D
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City | PICAYUNE
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State | MS
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Zip | 39466
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Country | US
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Telephone | 228-216-0528
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Fax | 769-242-2556
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Provider Business Mailing Address
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Address Line | 4201 HIGHWAY 11 N STE D
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City | PICAYUNE
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State | MS
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Zip | 39466-2014
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Country | US
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Telephone | 228-216-0528
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Fax | 769-242-2556
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Authorized Official
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Title or Position | OWNER
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Name | WILLIAM J KENNY
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Credential | CP
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Telephone | 228-216-0528
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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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