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General NPI Number Information
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NPI Number | 1407348808
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Entity Type | Organization
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Legal Business Name | GENTLE ROOTS LLC
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Dates
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Enumeration Date | 05/31/2018
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Last Update Date | 05/31/2018
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Provider Practice Location Address
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Address Line | 111 E 1ST ST
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City | SANFORD
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State | FL
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Zip | 32771-1301
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Country | US
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Telephone | 407-803-1890
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Fax |
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Provider Business Mailing Address
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Address Line | 3040 FOXHILL CIR APT 108
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City | APOPKA
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State | FL
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Zip | 32703-8145
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Country | US
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Telephone | 407-803-1890
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Fax |
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Authorized Official
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Title or Position | DOCTOR OF ORIENTAL MEDICINE
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Name | MS. KIRA RIO BOGUSLAW
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Credential | D.O.M.
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Telephone | 407-803-1890
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | AP3844
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License Number State | FL
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