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General NPI Number Information
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NPI Number | 1285099804
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Entity Type | Organization
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Legal Business Name | CHARLOTTE RESTORATION
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Dates
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Enumeration Date | 12/25/2015
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Last Update Date | 12/25/2015
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Provider Practice Location Address
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Address Line | 5970 FAIRVIEW RD SUITE 215
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City | CHARLOTTE
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State | NC
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Zip | 28210-3167
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Country | US
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Telephone | 704-617-2649
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Fax |
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Provider Business Mailing Address
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Address Line | 5970 FAIRVIEW RD SUITE 215
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City | CHARLOTTE
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State | NC
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Zip | 28210-3167
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Country | US
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Telephone | 704-617-2649
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | ERIC SEMEKO
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Credential | M.D.
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Telephone | 704-617-2649
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 200400163
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License Number State | NC
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