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General NPI Number Information
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NPI Number | 1972545218
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Entity Type | Organization
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Legal Business Name | SOUTH MOORE MEDICAL CLINIC,PC
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Dates
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Enumeration Date | 06/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 14800 S WESTERN AVE
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City | MOORE
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State | OK
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Zip | 73170-7112
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Country | US
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Telephone | 405-912-4900
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Fax | 405-912-4903
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Provider Business Mailing Address
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Address Line | PO BOX 25887
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City | OKLAHOMA CITY
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State | OK
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Zip | 73125-0887
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Country | US
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Telephone | 405-912-4900
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Fax | 405-912-4903
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Authorized Official
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Title or Position | PHYSICIAN
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Name | KEITH R. LAYNE
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Credential | M.D.
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Telephone | 405-912-4900
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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 |
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License Number State |
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