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General NPI Number Information
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NPI Number | 1306015748
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Entity Type | Organization
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Legal Business Name | LAKE FOOT CLINIC INC
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Dates
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Enumeration Date | 02/29/2008
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Last Update Date | 11/12/2008
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Provider Practice Location Address
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Address Line | 629 S GROVE ST
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City | EUSTIS
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State | FL
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Zip | 32726
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Country | US
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Telephone | 352-589-1335
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Fax | 352-589-1336
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Provider Business Mailing Address
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Address Line | 629 S GROVE ST
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City | EUSTIS
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State | FL
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Zip | 32726
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Country | US
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Telephone | 352-589-1335
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Fax | 352-589-1336
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Authorized Official
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Title or Position | PRESIDENT OWNER OF LAKE FOOT CLINIC
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Name | DR. JAMES T ROTELLA
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Credential | DPM
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Telephone | 352-589-1335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | PO1193
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License Number State | FL
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