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General NPI Number Information
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NPI Number | 1295960276
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Entity Type | Organization
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Legal Business Name | BODY GENESIS CENTER FOR INTEGRATIVE MEDICINE LLC
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Dates
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Enumeration Date | 05/20/2009
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Last Update Date | 05/20/2009
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Provider Practice Location Address
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Address Line | 937 S MANNHEIM RD
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City | WESTCHESTER
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State | IL
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Zip | 60154-2552
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Country | US
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Telephone | 708-343-3368
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Fax |
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Provider Business Mailing Address
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Address Line | 937 S MANNHEIM RD
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City | WESTCHESTER
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State | IL
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Zip | 60154-2552
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Country | US
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Telephone | 708-343-3368
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Fax |
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | DR. SOLOMON LIBURD
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Credential | DO
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Telephone | 708-343-3368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 038.010603
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License Number State | IL
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