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General NPI Number Information
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NPI Number | 1659522829
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Entity Type | Organization
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Legal Business Name | SUPPLEMENTAL
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Dates
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Enumeration Date | 10/07/2008
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Last Update Date | 10/07/2008
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Provider Practice Location Address
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Address Line | 20 NE SAINT LUKES BLVD SUITE 100
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City | LEES SUMMIT
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State | MO
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Zip | 64086-6001
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Country | US
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Telephone | 816-347-5748
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Fax | 816-347-5798
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Provider Business Mailing Address
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Address Line | 313B SE MELODY LN
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City | LEES SUMMIT
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State | MO
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Zip | 64063-2915
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Country | US
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Telephone | 816-682-7197
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Fax | 816-347-5798
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Authorized Official
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Title or Position | PHYSICAL THERAPIST ASSISTANT
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Name | MRS. KERRI LYN SWICK
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Credential | A.S.
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Telephone | 816-347-5748
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 273Y00000X
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Taxonomy Name | Rehabilitation Hospital Unit
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License Number | 2007023014
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License Number State | MO
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