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General NPI Number Information
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NPI Number | 1316090889
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Entity Type | Organization
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Legal Business Name | SOUTHEASTERN HEALTHCARE OF JACKSONVILLE, PC
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Dates
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Enumeration Date | 01/19/2007
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Last Update Date | 10/01/2007
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Provider Practice Location Address
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Address Line | 431 WESTERN BLVD SUITE E
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City | JACKSONVILLE
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State | NC
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Zip | 28546-6823
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Country | US
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Telephone | 910-355-6000
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Fax | 910-355-7533
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Provider Business Mailing Address
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Address Line | 2595 S 17TH ST
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City | WILMINGTON
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State | NC
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Zip | 28401-7748
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Country | US
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Telephone | 910-791-2788
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. ELIZA R. GRAY
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Credential |
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Telephone | 910-791-2788
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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 | 3421
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License Number State | NC
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