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General NPI Number Information
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NPI Number | 1396298915
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Entity Type | Organization
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Legal Business Name | LAVON M. GAINEY
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Dates
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Enumeration Date | 08/01/2016
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Last Update Date | 08/01/2016
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Provider Practice Location Address
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Address Line | 11265 ALUMNI WAY
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City | JACKSONVILLE
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State | FL
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Zip | 32246-6685
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Country | US
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Telephone | 904-518-6090
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Fax |
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Provider Business Mailing Address
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Address Line | 11265 ALUMNI WAY
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City | JACKSONVILLE
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State | FL
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Zip | 32246-6685
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Country | US
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Telephone | 904-518-6090
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. MARCUS DE CARVALHO
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Credential | M.D.
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Telephone | 904-398-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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