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General NPI Number Information
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NPI Number | 1619922515
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Entity Type | Organization
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Legal Business Name | BELVIDERE REHAB & SPORTS MEDICINE
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 01/08/2013
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Provider Practice Location Address
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Address Line | 1255 LOGAN AVE
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City | BELVIDERE
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State | IL
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Zip | 61008-4001
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Country | US
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Telephone | 815-547-4733
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Fax | 815-547-9733
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Provider Business Mailing Address
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Address Line | 2662 MCFARLAND RD
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City | ROCKFORD
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State | IL
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Zip | 61107-6806
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Country | US
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Telephone | 815-547-4733
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Fax | 815-547-9733
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Authorized Official
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Title or Position | OWNER/EXECUTIVE OFFICER
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Name | DAVID A BLACK
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Credential | PT, MS, OCS
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Telephone | 815-227-1700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 060-008176
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License Number State | IL
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