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General NPI Number Information
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NPI Number | 1750663571
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Entity Type | Organization
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Legal Business Name | RIVER VALLEY FOOT & ANKLE CLINIC
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Dates
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Enumeration Date | 09/19/2011
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Last Update Date | 01/19/2012
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Provider Practice Location Address
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Address Line | 703 W MAIN ST
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City | RUSSELLVILLE
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State | AR
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Zip | 72801-3616
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Country | US
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Telephone | 479-968-3338
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 10424
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City | RUSSELLVILLE
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State | AR
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Zip | 72812
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Country | US
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Telephone | 479-647-6443
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Fax |
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Authorized Official
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Title or Position | PODIATRIST
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Name | DR. STEPHANIE ROTH
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Credential | DPM
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Telephone | 479-968-3338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 245
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License Number State | AR
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