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General NPI Number Information
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NPI Number | 1699964171
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Entity Type | Organization
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Legal Business Name | LOCUST GROVE CLINIC, P.C.
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Dates
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Enumeration Date | 10/19/2007
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Last Update Date | 10/19/2007
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Provider Practice Location Address
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Address Line | 2648 HIGHWAY 42
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City | LOCUST GROVE
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State | GA
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Zip | 30248-2519
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Country | US
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Telephone | 770-898-0028
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Fax | 770-898-7987
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Provider Business Mailing Address
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Address Line | 2648 HIGHWAY 42
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City | LOCUST GROVE
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State | GA
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Zip | 30248-2519
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Country | US
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Telephone | 770-898-0028
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Fax | 770-898-7987
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Authorized Official
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Title or Position | PRES
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Name | DR. PETER J TULLY
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Credential | D.C.
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Telephone | 770-898-0028
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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 | CHIROO6323
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License Number State | GA
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