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General NPI Number Information
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NPI Number | 1255776613
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Entity Type | Organization
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Legal Business Name | CEDAR GROVE REHAB LLC
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Dates
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Enumeration Date | 04/30/2013
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Last Update Date | 04/30/2013
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Provider Practice Location Address
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Address Line | 3395 BOULDERCREST RD
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City | ELLENWOOD
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State | GA
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Zip | 30294-1639
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Country | US
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Telephone | 404-241-3280
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Fax |
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Provider Business Mailing Address
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Address Line | 3395 BOULDERCREST RD
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City | ELLENWOOD
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State | GA
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Zip | 30294-1639
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Country | US
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Telephone | 404-241-3280
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Fax |
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Authorized Official
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Title or Position | ATTORNEY
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Name | MR. OTIS L BONNER III
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Credential |
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Telephone | 770-940-4975
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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