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General NPI Number Information
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NPI Number | 1508080417
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Entity Type | Organization
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Legal Business Name | ANKLE AND FOOT CENTER OF GEORGIA,LLC
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 06/10/2008
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Provider Practice Location Address
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Address Line | 2700 HIGHWAY 34 E BLDG 200
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City | NEWNAN
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State | GA
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Zip | 30265-2315
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Country | US
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Telephone | 770-755-1949
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Fax | 770-783-0294
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Provider Business Mailing Address
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Address Line | 1555 DOCTORS DR SUITE 106
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City | LAGRANGE
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State | GA
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Zip | 30240-4132
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Country | US
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Telephone | 770-755-1949
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Fax | 770-783-0294
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Authorized Official
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Title or Position | OWNER
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Name | DR. RICHARD P HOLLSTROM JR.
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Credential | DPM
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Telephone | 770-755-1949
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number |
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License Number State | GA
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