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General NPI Number Information
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NPI Number | 1710384979
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Entity Type | Organization
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Legal Business Name | GBT LBA
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Dates
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Enumeration Date | 12/03/2014
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Last Update Date | 12/03/2014
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Provider Practice Location Address
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Address Line | 3101 UNIVERSITY BLVD S SUITE 203
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City | JACKSONVILLE
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State | FL
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Zip | 32216-2790
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Country | US
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Telephone | 904-518-9654
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Fax | 904-724-5770
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Provider Business Mailing Address
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Address Line | 2895 EGRET CT
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City | NORTH PORT
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State | FL
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Zip | 34287-2369
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Country | US
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Telephone | 904-518-9654
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Fax | 904-724-5770
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JAMES COKER
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Credential |
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Telephone | 904-518-9654
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number | 208VP0014X
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License Number State | FL
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