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General NPI Number Information
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NPI Number | 1306460308
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Entity Type | Organization
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Legal Business Name | PURPLE ARCH NEURO REHABILITATION, LLC
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Dates
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Enumeration Date | 06/04/2020
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Last Update Date | 06/04/2020
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Provider Practice Location Address
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Address Line | 53359 CHAMPLAIN ST
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City | MACOMB
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State | MI
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Zip | 48042-3739
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Country | US
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Telephone | 586-859-9607
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Fax |
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Provider Business Mailing Address
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Address Line | 53359 CHAMPLAIN ST
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City | MACOMB
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State | MI
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Zip | 48042-3739
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Country | US
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Telephone | 586-859-9607
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Fax |
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Authorized Official
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Title or Position | OWNER, SPEECH-LANGUAGE PATHOLOGIST
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Name | DR. THOMAS LAURIE SOUTHERN JR.
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Credential | SLPD
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Telephone | 586-859-9607
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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