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General NPI Number Information
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NPI Number | 1235481524
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Entity Type | Organization
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Legal Business Name | 1 SOURCE CHIROPRACTIC & PHYSICAL MEDICINE CENTER INC
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Dates
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Enumeration Date | 10/10/2012
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Last Update Date | 01/22/2013
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Provider Practice Location Address
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Address Line | 2718 LETAP CT
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City | LAND O LAKES
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State | FL
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Zip | 34638-7218
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Country | US
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Telephone | 813-448-2222
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Fax | 813-948-7111
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Provider Business Mailing Address
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Address Line | 2718 LETAP CT
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City | LAND O LAKES
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State | FL
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Zip | 34638-7218
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Country | US
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Telephone | 813-448-2222
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Fax | 813-948-7111
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Authorized Official
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Title or Position | OWNER/DOCTOR
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Name | DR. JORGE LUIS SANTANA
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Credential | D.C.
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Telephone | 813-448-2222
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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 | CH8357
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | ME114962
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License Number State | FL
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