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General NPI Number Information
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NPI Number | 1447490453
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Entity Type | Organization
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Legal Business Name | LESLIE CLINIC INC.
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Dates
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Enumeration Date | 03/03/2009
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Last Update Date | 03/03/2009
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Provider Practice Location Address
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Address Line | RR 1 BOX A1
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City | VICI
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State | OK
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Zip | 73859-9106
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Country | US
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Telephone | 580-995-3200
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Fax | 580-995-3202
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Provider Business Mailing Address
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Address Line | PO BOX 45
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City | VICI
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State | OK
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Zip | 73859-0045
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Country | US
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Telephone | 580-995-3200
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Fax | 580-995-3202
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Authorized Official
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Title or Position | MEDICAL DOCTOR/PRACTICE OWNER
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Name | DR. PORTER BASS LESLIE
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Credential | M.D.
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Telephone | 580-995-3200
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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 | 10616
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License Number State | OK
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