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General NPI Number Information
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NPI Number | 1225268451
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Entity Type | Individual
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Provider Name | BRADLEY ELLIOTT BORELLO OD
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Gender | Male
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Dates
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Enumeration Date | 07/22/2009
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Last Update Date | 11/10/2021
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Provider Practice Location Address
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Address Line | 12392 OLIVE BLVD
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City | CREVE COEUR
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State | MO
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Zip | 63141-6443
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Country | US
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Telephone | 314-878-8770
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Fax | 314-878-5971
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Provider Business Mailing Address
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Address Line | 1384 S 5TH ST
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City | SAINT CHARLES
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State | MO
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Zip | 63301-2444
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Country | US
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Telephone | 636-946-9242
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Fax | 636-946-4903
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2009016924
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License Number State | MO
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