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General NPI Number Information
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NPI Number | 1437221819
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Entity Type | Organization
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Legal Business Name | CHIROPRACTIC BACK PAIN CLINIC
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Dates
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Enumeration Date | 11/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2645 SW 37TH AVE SUITE 704
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City | MIAMI
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State | FL
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Zip | 33133-2754
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Country | US
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Telephone | 305-774-1119
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Fax | 305-774-1141
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Provider Business Mailing Address
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Address Line | 1029 MALAGA AVE
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City | CORAL GABLES
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State | FL
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Zip | 33134-6318
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Country | US
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Telephone | 305-448-8251
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. OCTAVIO P. FERNANDEZ
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Credential | D.C.
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Telephone | 305-774-6923
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH6723
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License Number State | FL
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