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General NPI Number Information
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NPI Number | 1609309798
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Entity Type | Organization
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Legal Business Name | SOUTHERN ROOTS IN-HOME CARE LLC
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Dates
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Enumeration Date | 04/06/2017
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Last Update Date | 04/06/2017
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Provider Practice Location Address
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Address Line | 301 S BENTON ST MH
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City | MOREHOUSE
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State | MO
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Zip | 63868-0301
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Country | US
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Telephone | 573-667-0028
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Fax | 573-667-0028
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Provider Business Mailing Address
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Address Line | 301 S BENTON ST MH
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City | SIKESTON
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State | MO
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Zip | 63801-0301
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Country | US
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Telephone | 573-667-0028
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Fax | 573-667-0028
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Authorized Official
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Title or Position | OWNER
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Name | MRS. BARBARA LYNN SQUIRES
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Credential |
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Telephone | 573-703-2229
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 985864
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License Number State | MO
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