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General NPI Number Information
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NPI Number | 1588818975
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Entity Type | Organization
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Legal Business Name | DCCT
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Dates
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Enumeration Date | 11/11/2008
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Last Update Date | 11/13/2008
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Provider Practice Location Address
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Address Line | 1423 S BIG BEND BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63117-2203
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Country | US
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Telephone | 314-610-8169
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 9169
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City | SAINT LOUIS
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State | MO
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Zip | 63117-0169
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Country | US
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Telephone | 314-610-8169
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. REZA ROFOUGARAN
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Credential | MD
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Telephone | 314-610-8169
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 101819
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License Number State | MO
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