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General NPI Number Information
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NPI Number | 1578751889
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Entity Type | Organization
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Legal Business Name | CHIRO/PRACTICAL
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Dates
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Enumeration Date | 10/11/2007
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Last Update Date | 10/12/2010
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Provider Practice Location Address
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Address Line | 5626 MAIN ST
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City | ZACHARY
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State | LA
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Zip | 70791-4023
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Country | US
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Telephone | 225-658-0500
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Fax | 225-658-9414
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Provider Business Mailing Address
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Address Line | 5626 MAIN ST
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City | ZACHARY
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State | LA
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Zip | 70791-4023
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Country | US
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Telephone | 225-658-0500
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Fax | 225-658-9414
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | MATTHEW JAMES SIMONSON
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Credential | D.C.
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Telephone | 225-658-0500
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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 | 1211
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License Number State | LA
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