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General NPI Number Information
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NPI Number | 1821380866
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Entity Type | Organization
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Legal Business Name | CANEBRAKE MEDICAL MANAGEMENT
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Dates
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Enumeration Date | 05/10/2011
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Last Update Date | 10/14/2011
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Provider Practice Location Address
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Address Line | 123 E CAPITOL ST
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City | DEMOPOLIS
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State | AL
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Zip | 36732-2218
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Country | US
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Telephone | 334-289-9408
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Fax |
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Provider Business Mailing Address
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Address Line | 123 E CAPITOL ST
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City | DEMOPOLIS
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State | AL
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Zip | 36732-2218
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Country | US
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Telephone | 334-289-9408
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Fax |
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Authorized Official
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Title or Position | CRNP
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Name | MRS. TERRE M. MOORE
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Credential | CRNP
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Telephone | 334-289-9408
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 11061
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License Number State | AL
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