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General NPI Number Information
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NPI Number | 1972850949
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Entity Type | Organization
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Legal Business Name | DOC'S PT LLC
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Dates
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Enumeration Date | 08/09/2012
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Last Update Date | 08/09/2012
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Provider Practice Location Address
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Address Line | 1211 WASHINGTON AVE
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City | WILMETTE
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State | IL
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Zip | 60091-2520
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Country | US
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Telephone | 847-542-4868
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Fax |
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Provider Business Mailing Address
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Address Line | 1898 MCRAE LN
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City | MUNDELEIN
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State | IL
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Zip | 60060-1468
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Country | US
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Telephone | 847-542-4868
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RICHARD BRYANT COLOSI
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Credential | DPT, FAFS, FMR
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Telephone | 847-542-4868
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 070014101
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License Number State | IL
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