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General NPI Number Information
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NPI Number | 1538477690
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Entity Type | Organization
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Legal Business Name | SPINE CLINIC, LLC
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Dates
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Enumeration Date | 09/22/2010
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Last Update Date | 03/14/2013
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Provider Practice Location Address
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Address Line | 15 N MAIN ST
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City | FORT SCOTT
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State | KS
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Zip | 66701-1410
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Country | US
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Telephone | 620-223-2990
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Fax | 620-223-2991
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Provider Business Mailing Address
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Address Line | PO BOX 589
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City | FORT SCOTT
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State | KS
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Zip | 66701-0589
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Country | US
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Telephone | 620-223-2990
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Fax | 620-223-2991
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | DR. LUCAS BRENT COSENS SR.
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Credential | D.C.
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Telephone | 620-223-2990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2010013287
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 01-05329
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License Number State | KS
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