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General NPI Number Information
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NPI Number | 1760716583
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Entity Type | Organization
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Legal Business Name | ROOSEVELT FAMILY CHIROPRACTIC, PC
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Dates
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Enumeration Date | 09/25/2009
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Last Update Date | 09/25/2009
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Provider Practice Location Address
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Address Line | 6317 ROOSEVELT AVE
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City | WOODSIDE
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State | NY
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Zip | 11377-3641
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Country | US
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Telephone | 718-335-7700
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Fax | 718-335-2254
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Provider Business Mailing Address
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Address Line | 6317 ROOSEVELT AVE
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City | WOODSIDE
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State | NY
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Zip | 11377-3641
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Country | US
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Telephone | 718-335-7700
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Fax | 718-335-2254
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Authorized Official
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Title or Position | OWNER
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Name | DR. MEHRZAD ISSAC KOHANSIEH
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Credential | DC
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Telephone | 718-335-7700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | XOO7887-1
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License Number State | NY
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