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General NPI Number Information
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NPI Number | 1730180704
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Entity Type | Individual
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Provider Name | CORY J. BOSANKO O.D.
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Gender | Male
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Dates
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Enumeration Date | 08/02/2005
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Last Update Date | 01/22/2021
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Provider Practice Location Address
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Address Line | 39 LANTANA RD
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City | CROSSVILLE
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State | TN
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Zip | 38555-4901
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Country | US
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Telephone | 931-484-3344
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Fax | 931-456-3671
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Provider Business Mailing Address
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Address Line | 39 LANTANA RD
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City | CROSSVILLE
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State | TN
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Zip | 38555-4901
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Country | US
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Telephone | 931-484-3344
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Fax | 931-456-3671
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WL0500X
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Taxonomy Name | Low Vision Rehabilitation Optometrist
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License Number | OD0000002541
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OD2541
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License Number State | TN
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