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General NPI Number Information
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NPI Number | 1447461900
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Entity Type | Organization
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Legal Business Name | SOUTH LOGAN FAMILY PRACTICE
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Dates
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Enumeration Date | 05/25/2007
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Last Update Date | 07/02/2008
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Provider Practice Location Address
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Address Line | 1808 EAST MAIN
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City | BOONEVILLE
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State | AR
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Zip | 72927-1373
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Country | US
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Telephone | 479-675-2228
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Fax | 479-675-2274
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Provider Business Mailing Address
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Address Line | PO BOX 1373
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City | BOONEVILLE
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State | AR
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Zip | 72927-0301
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Country | US
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Telephone | 479-675-2228
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Fax | 479-675-2274
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | MR. CLARENCE JAY ARENDALL
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Credential | M.D.
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Telephone | 479-675-2228
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | E3514
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License Number State | AR
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