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General NPI Number Information
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NPI Number | 1891192068
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Entity Type | Organization
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Legal Business Name | YOUR FAMILY CLINIC LLC
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Dates
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Enumeration Date | 12/03/2014
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Last Update Date | 12/03/2014
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Provider Practice Location Address
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Address Line | 514 OLD RICHTON RD
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City | PETAL
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State | MS
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Zip | 39465-2920
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Country | US
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Telephone | 601-544-8935
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Fax | 601-544-8935
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Provider Business Mailing Address
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Address Line | 67 MARS HILL RD
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City | PETAL
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State | MS
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Zip | 39465-8343
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Country | US
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Telephone | 601-544-8935
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Fax | 601-544-8935
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Authorized Official
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Title or Position | OWNER
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Name | DANIEL TAMOUR MOORE
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Credential | PH.D.
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Telephone | 601-544-8935
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 948493
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License Number State | MS
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