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General NPI Number Information
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NPI Number | 1679766711
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Entity Type | Organization
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Legal Business Name | ADVANCED ORTHO REHAB, P.A.
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Dates
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Enumeration Date | 08/22/2007
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Last Update Date | 02/13/2012
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Provider Practice Location Address
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Address Line | 1 LAKESHORE DR STE 1620
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City | LAKE CHARLES
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State | LA
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Zip | 70629-0104
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Country | US
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Telephone | 337-439-7007
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Fax | 337-439-7011
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Provider Business Mailing Address
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Address Line | 1 LAKESHORE DR STE 1670
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City | LAKE CHARLES
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State | LA
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Zip | 70629-0114
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Country | US
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Telephone | 337-439-7007
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Fax | 337-439-7011
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Authorized Official
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Title or Position | PROPRIETOR
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Name | SAMUEL E LISCUM
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Credential | D.C.
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Telephone | 337-439-7007
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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 | 1563
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License Number State | LA
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