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General NPI Number Information
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NPI Number | 1386997781
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Entity Type | Organization
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Legal Business Name | GENESIS
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Dates
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Enumeration Date | 10/23/2012
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Last Update Date | 10/23/2012
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Provider Practice Location Address
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Address Line | 1513 S DIXIELAND RD
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City | ROGERS
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State | AR
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Zip | 72758-4935
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Country | US
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Telephone | 479-636-5841
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Fax |
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Provider Business Mailing Address
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Address Line | 4106 CANDLEWOOD PL
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City | ROGERS
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State | AR
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Zip | 72758-8253
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Country | US
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Telephone | 479-263-1268
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPY ASSISTANT
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Name | MR. MICHAEL DAVID
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Credential | PTA
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Telephone | 479-330-0187
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | OTR1586
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License Number State | AR
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