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General NPI Number Information
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NPI Number | 1760017305
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Entity Type | Organization
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Legal Business Name | DIVERSIFIED MEDICAL SERVICES, LLC
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Dates
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Enumeration Date | 03/04/2020
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Last Update Date | 03/04/2020
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Provider Practice Location Address
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Address Line | 2305 S PURPERA AVE
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City | GONZALES
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State | LA
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Zip | 70737-5427
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Country | US
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Telephone | 225-644-1028
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Fax |
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Provider Business Mailing Address
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Address Line | 106 TENTH ST
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City | BAY ST LOUIS
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State | MS
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Zip | 39520-2409
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Country | US
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Telephone | 985-249-1683
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Fax |
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MR. ANTHONY SALVATORE BROCATO JR.
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Credential |
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Telephone | 985-249-1683
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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