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General NPI Number Information
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NPI Number | 1336366400
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Entity Type | Organization
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Legal Business Name | BACK IN MOTION SPINAL CLINIC,INC
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2704 N UNIVERSITY DR
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City | SUNRISE
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State | FL
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Zip | 33322-2435
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Country | US
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Telephone | 954-748-1004
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Fax |
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Provider Business Mailing Address
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Address Line | 2704 N UNIVERSITY DR
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City | SUNRISE
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State | FL
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Zip | 33322-2435
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Country | US
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Telephone | 954-748-1004
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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. BRYAN HARRIS KALODISH
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Credential | DC
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Telephone | 954-748-1004
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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 | CH0007076
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License Number State | FL
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