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General NPI Number Information
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NPI Number | 1730346065
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Entity Type | Organization
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Legal Business Name | SOUTH BREVARD HOLISTIC CENTER, INC.
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Dates
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Enumeration Date | 05/22/2008
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Last Update Date | 05/22/2008
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Provider Practice Location Address
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Address Line | 2174 HARRIS AVE NE SUITE 3
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City | PALM BAY
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State | FL
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Zip | 32905-4040
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Country | US
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Telephone | 321-574-5719
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Fax | 321-952-0697
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Provider Business Mailing Address
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Address Line | 2174 HARRIS AVE NE SUITE 3
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City | PALM BAY
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State | FL
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Zip | 32905-4040
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Country | US
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Telephone | 321-574-5719
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Fax | 321-952-0697
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Authorized Official
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Title or Position | MASSAGE THERAPIST/MANAGER
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Name | MRS. CHESLYE PHILOCHE
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Credential | LMT
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Telephone | 321-574-5719
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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 | HCC7823
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License Number State | FL
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