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General NPI Number Information
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NPI Number | 1396287264
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Entity Type | Organization
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Legal Business Name | PHASES DETOX, LLC
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Dates
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Enumeration Date | 11/09/2016
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Last Update Date | 11/09/2016
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Provider Practice Location Address
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Address Line | 1870 FOREST HILL BLVD SUITE 204
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City | WEST PALM BEACH
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State | FL
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Zip | 33406-8901
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Country | US
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Telephone | 732-910-1427
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Fax | 561-907-4948
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Provider Business Mailing Address
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Address Line | 718 FRANKLIN RD
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City | WEST PALM BEACH
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State | FL
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Zip | 33405-4208
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Country | US
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Telephone | 732-910-1427
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Fax | 561-907-4948
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Authorized Official
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Title or Position | OWNER
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Name | SHANE KOHAN
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Credential |
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Telephone | 732-910-1427
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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