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General NPI Number Information
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NPI Number | 1427078369
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Entity Type | Organization
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Legal Business Name | MYOFASCIAL RELEASE THERAPY, LLC
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Dates
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Enumeration Date | 07/21/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1405 W REYNOLDS ST
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City | PONTIAC
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State | IL
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Zip | 61764-0468
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Country | US
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Telephone | 815-844-2464
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Fax | 815-842-1024
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Provider Business Mailing Address
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Address Line | 1405 W REYNOLDS ST PO BOX 468
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City | PONTIAC
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State | IL
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Zip | 61764-0468
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Country | US
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Telephone | 815-844-2464
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Fax | 815-842-1024
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Authorized Official
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Title or Position | OWNER
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Name | LINDA G CARLEY
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Credential | P.T.
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Telephone | 815-844-2464
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State | IL
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