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General NPI Number Information
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NPI Number | 1700104528
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Entity Type | Organization
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Legal Business Name | EXECUTIVE MANAGEMENT FOR ADULT CARE LLC
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Dates
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Enumeration Date | 05/05/2010
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Last Update Date | 08/12/2011
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Provider Practice Location Address
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Address Line | 15660 SAN CARLOS BLVD UNIT # 294
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City | FORT MYERS
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State | FL
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Zip | 33908-2526
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Country | US
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Telephone | 239-338-8069
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Fax |
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Provider Business Mailing Address
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Address Line | 15660 SAN CARLOS BLVD UNIT # 294
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City | FORT MYERS
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State | FL
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Zip | 33908-2526
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Country | US
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Telephone | 239-338-8069
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Fax |
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Authorized Official
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Title or Position | DIRECT OWNER
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Name | DR. MARCIA ELIZABETH FOWLER
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Credential | D.O.
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Telephone | 239-338-8069
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | OS7238
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License Number State | FL
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