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General NPI Number Information
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NPI Number | 1942067939
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Entity Type | Organization
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Legal Business Name | ORTHOTIC & PROSTHETIC CLINIC OF JACKSONVILLE, LLC
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Dates
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Enumeration Date | 03/05/2024
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Last Update Date | 03/05/2024
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Provider Practice Location Address
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Address Line | 11512 LAKE MEAD AVE UNIT 404
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City | JACKSONVILLE
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State | FL
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Zip | 32256-9687
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Country | US
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Telephone | 904-231-8440
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Fax | 904-231-8441
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Provider Business Mailing Address
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Address Line | 2754 NW 27TH AVE
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City | BOCA RATON
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State | FL
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Zip | 33434-3692
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Country | US
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Telephone | 305-812-5087
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Fax |
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Authorized Official
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Title or Position | OWNER / AMBR
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Name | MR. RAFAEL AGUSTIN DIAZ ABREU
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Credential |
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Telephone | 305-812-5087
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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