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General NPI Number Information
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NPI Number | 1689292278
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Entity Type | Individual
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Provider Name | AGATA M FOREMAN
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Gender | Female
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Dates
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Enumeration Date | 07/09/2020
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Last Update Date | 07/09/2020
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Provider Practice Location Address
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Address Line | 333 COMMERCE DR STE 175
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-3596
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Country | US
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Telephone | 224-704-9218
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Fax |
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Provider Business Mailing Address
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Address Line | 6420 LAKEWOOD DR
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City | CARY
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State | IL
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Zip | 60013-1239
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Country | US
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Telephone | 224-704-9218
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 02.021803
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License Number State | IL
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