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General NPI Number Information
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NPI Number | 1700055423
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Entity Type | Organization
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Legal Business Name | LAKESIDE FAMILY CARE CLINIC
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Dates
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Enumeration Date | 02/27/2008
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Last Update Date | 02/27/2008
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Provider Practice Location Address
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Address Line | 900 WHITEHEAD DR.
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City | GRANBURY
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State | TX
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Zip | 76048
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Country | US
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Telephone | 817-573-8320
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Fax | 817-573-8294
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Provider Business Mailing Address
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Address Line | PO BOX 2249
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City | GRANBURY
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State | TX
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Zip | 76048-7249
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Country | US
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Telephone | 817-573-8320
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Fax | 817-573-8294
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Authorized Official
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Title or Position | DOCTOR
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Name | JUDITH ABIGAIL MOSS
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Credential | D.O.
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Telephone | 817-573-8320
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | J6020
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License Number State | TX
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