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General NPI Number Information
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NPI Number | 1275956286
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Entity Type | Organization
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Legal Business Name | DIRECTOR
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Dates
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Enumeration Date | 01/27/2014
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Last Update Date | 01/27/2014
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Provider Practice Location Address
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Address Line | 625 N EUCLID AVE STE 302
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City | SAINT LOUIS
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State | MO
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Zip | 63108-1690
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Country | US
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Telephone | 314-825-2084
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Fax |
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Provider Business Mailing Address
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Address Line | 1112 WILD PLUM DR
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City | SAINT PETERS
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State | MO
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Zip | 63303-1208
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR/COORDINATOR
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Name | MARCUS DICKINSON
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Credential |
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Telephone | 314-825-2084
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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