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General NPI Number Information
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NPI Number | 1700313293
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Entity Type | Organization
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Legal Business Name | COMPLETE LASER CLINIC OF LOUISVILLE, LLC
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Dates
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Enumeration Date | 05/16/2017
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Last Update Date | 05/16/2017
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Provider Practice Location Address
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Address Line | 3000 FERN VALLEY RD
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City | LOUISVILLE
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State | KY
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Zip | 40213-3522
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Country | US
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Telephone | 502-208-1803
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3805
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City | LOUISVILLE
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State | KY
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Zip | 40201-3805
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Country | US
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Telephone | 502-208-1803
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | CARY STORY
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Credential |
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Telephone | 502-208-1803
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State | KY
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