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General NPI Number Information
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NPI Number | 1972911725
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Entity Type | Organization
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Legal Business Name | REALISTIC MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 07/24/2014
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Last Update Date | 04/20/2015
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Provider Practice Location Address
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Address Line | 2646 S LOOP W SUITE 520
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City | HOUSTON
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State | TX
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Zip | 77054-2665
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Country | US
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Telephone | 713-434-5877
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Fax | 832-834-7539
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Provider Business Mailing Address
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Address Line | 2646 SOUTH LOOP WEST SUITE 520
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City | HOUSTON
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State | TX
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Zip | 77054
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Country | US
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Telephone | 713-434-5877
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Fax | 832-834-7539
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | LLOYD DAVID RANDALL
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Credential |
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Telephone | 713-434-5877
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number |
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License Number State |
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