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Individual
MARC ODA
Active
Individual
MARC ODA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPT
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
070026495
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
6305532111
PHONE NUMBER
—
Enumeration date
12/27/2022
Last updated
12/27/2022
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