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General NPI Number Information
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NPI Number | 1245571660
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Entity Type | Organization
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Legal Business Name | NV ORTHOTICS
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Dates
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Enumeration Date | 03/11/2013
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Last Update Date | 03/11/2013
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Provider Practice Location Address
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Address Line | 1675 W DEMPSTER ST
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City | PARK RIDGE
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State | IL
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Zip | 60068-1110
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Country | US
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Telephone | 708-651-2564
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Fax |
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Provider Business Mailing Address
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Address Line | 5131 ELLINGTON AVE
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City | WESTERN SPRINGS
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State | IL
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Zip | 60558-2034
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Country | US
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Telephone | 708-651-2564
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Fax |
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Authorized Official
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Title or Position | OWNER/ORTHOTIST
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Name | MR. ROBERT ALLEN NOVAK
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Credential | CO
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Telephone | 708-651-2564
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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 | 04254422
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License Number State | IL
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