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General NPI Number Information
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NPI Number | 1366064214
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Entity Type | Organization
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Legal Business Name | RADIANT WELLNESS CENTER LLC
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Dates
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Enumeration Date | 05/14/2020
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Last Update Date | 05/14/2020
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Provider Practice Location Address
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Address Line | 556 1ST AVE N
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City | ST PETERSBURG
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State | FL
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Zip | 33701-3702
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Country | US
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Telephone | 727-954-5596
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Fax |
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Provider Business Mailing Address
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Address Line | 700 13TH AVE S
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City | ST PETERSBURG
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State | FL
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Zip | 33701-5310
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Country | US
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Telephone | 843-816-4274
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Fax |
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Authorized Official
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Title or Position | OWNER/DCOTOR
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Name | ASHLEY THERESE MARTIN
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Credential | DC
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Telephone | 843-816-4274
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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