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General NPI Number Information
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NPI Number | 1487817193
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Entity Type | Organization
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Legal Business Name | LIGHTS PROSTHETIC EYES INC
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Dates
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Enumeration Date | 07/03/2008
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Last Update Date | 07/09/2008
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Provider Practice Location Address
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Address Line | 1736 E SUNSHINE ST SUITE 404
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City | SPRINGFIELD
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State | MO
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Zip | 65804-1343
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Country | US
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Telephone | 417-889-0988
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Fax |
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Provider Business Mailing Address
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Address Line | 1318 W CANDLETREE DR SUITE 3
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City | PEORIA
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State | IL
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Zip | 61614-8508
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Country | US
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Telephone | 309-676-3663
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. RANDY L LIGHT
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Credential | BCO
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Telephone | 309-676-3663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1700X
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Taxonomy Name | Ocularist
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License Number | 17065569
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License Number State | MO
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