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General NPI Number Information
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NPI Number | 1295228039
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Entity Type | Organization
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Legal Business Name | DME DC PROVIDER LLC
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Dates
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Enumeration Date | 06/06/2018
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Last Update Date | 06/06/2018
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Provider Practice Location Address
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Address Line | 12641 SAN JOSE BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32223-2646
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Country | US
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Telephone | 904-606-6007
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Fax | 904-376-8738
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Provider Business Mailing Address
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Address Line | 848 BUCKEYE LN W
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City | SAINT JOHNS
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State | FL
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Zip | 32259-4387
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Country | US
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Telephone | 904-477-6644
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. NATHALIE BLUM
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Credential | DC
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Telephone | 904-477-6644
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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 | CH9429
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License Number State | FL
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