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General NPI Number Information
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NPI Number | 1366806945
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Entity Type | Organization
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Legal Business Name | RESURGENT MHT
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Dates
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Enumeration Date | 04/08/2016
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Last Update Date | 04/08/2016
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Provider Practice Location Address
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Address Line | 593 S HORSEBARN RD
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City | ROGERS
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State | AR
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Zip | 72758-8795
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Country | US
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Telephone | 479-657-4636
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Fax |
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Provider Business Mailing Address
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Address Line | 324 RAVENWOOD RD
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City | SILOAM SPRINGS
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State | AR
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Zip | 72761-5550
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Country | US
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Telephone | 479-220-2772
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DONALD E WLEKLINSKI
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Credential | APRN
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Telephone | 479-220-2772
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | A003818
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | A003818
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License Number State | AR
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