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General NPI Number Information
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NPI Number | 1528707585
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Entity Type | Organization
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Legal Business Name | BAY REJUVENATION
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Dates
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Enumeration Date | 05/29/2022
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Last Update Date | 05/29/2022
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Provider Practice Location Address
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Address Line | 309 REESE ST
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City | BAY SAINT LOUIS
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State | MS
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Zip | 39520-2823
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Country | US
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Telephone | 662-571-0916
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Fax |
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Provider Business Mailing Address
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Address Line | 309 REESE ST
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City | BAY SAINT LOUIS
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State | MS
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Zip | 39520-2823
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Country | US
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Telephone | 662-571-0916
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Fax |
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Authorized Official
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Title or Position | FAMILY NURSE PRACTITIONER
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Name | ALISA STEPHENS
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Credential | NP-C
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Telephone | 662-571-0916
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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