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General NPI Number Information
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NPI Number | 1669826574
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Entity Type | Organization
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Legal Business Name | ROOT CAUSE CLINIC, INCORPORATED
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Dates
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Enumeration Date | 04/17/2016
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Last Update Date | 12/29/2016
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Provider Practice Location Address
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Address Line | 15043 BRUCE B DOWNS BLVD
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City | TAMPA
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State | FL
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Zip | 33647-1388
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Country | US
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Telephone | 937-216-9048
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Fax |
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Provider Business Mailing Address
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Address Line | 5947 OLD BERKLEY RD
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City | AUBURNDALE
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State | FL
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Zip | 33823-8302
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Country | US
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Telephone | 937-216-9048
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JORDAN MATTHEW AXE
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Credential | DC
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Telephone | 937-216-9048
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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 | CH 11262
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License Number State | FL
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