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General NPI Number Information
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NPI Number | 1356520563
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Entity Type | Organization
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Legal Business Name | BOUC FAMILY WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 10/24/2007
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Last Update Date | 04/26/2018
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Provider Practice Location Address
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Address Line | 3005 RIVERSIDE DR SUITE 101
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City | BELOIT
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State | WI
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Zip | 53511-1500
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Country | US
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Telephone | 608-365-7200
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Fax | 608-365-7202
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Provider Business Mailing Address
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Address Line | 3005 RIVERSIDE DR SUITE 101
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City | BELOIT
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State | WI
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Zip | 53511-1500
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Country | US
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Telephone | 608-365-7200
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Fax | 608-365-7202
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. GEOFFREY T BOUC
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Credential | M.D.
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Telephone | 608-365-7200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 36893
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License Number State | WI
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