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General NPI Number Information
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NPI Number | 1417133265
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Entity Type | Organization
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Legal Business Name | LAKESIDE CHIROPRACTIC PC
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Dates
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Enumeration Date | 01/10/2008
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Last Update Date | 03/07/2008
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Provider Practice Location Address
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Address Line | 1640 E OLIVER PL
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City | SHOW LOW
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State | AZ
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Zip | 85901-6117
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Country | US
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Telephone | 928-532-1225
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Fax | 928-532-2276
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Provider Business Mailing Address
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Address Line | PO BOX 3330
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City | PINETOP
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State | AZ
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Zip | 85935-3330
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Country | US
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Telephone | 928-532-1225
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Fax | 928-532-2276
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RICHARD ALBERT BOATRIGHT
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Credential | D.C.
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Telephone | 928-532-1225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 5129
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License Number State | AZ
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