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General NPI Number Information
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NPI Number | 1902181233
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Entity Type | Organization
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Legal Business Name | ST. JOHN THERAPY SERVICES, INC.
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Dates
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Enumeration Date | 10/18/2011
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Last Update Date | 10/18/2011
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Provider Practice Location Address
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Address Line | 9111 BROADWAY SUITE MM
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City | MERRILLVILLE
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State | IN
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Zip | 46410-8122
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Country | US
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Telephone | 219-750-9763
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Fax |
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Provider Business Mailing Address
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Address Line | 10197 BACKWATER CV
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City | SAINT JOHN
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State | IN
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Zip | 46373-7008
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Country | US
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Telephone | 219-750-9763
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. IAN C CABALLES
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Credential | P.T
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Telephone | 219-716-0030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 05006512A
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License Number State | IN
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