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Please return to LifeGuard Electronically info LifeGuardProgram.com Via U.S. Postal Service LifeGuard 777 E. Park Drive Harrisburg PA 17111 Via HIPAA-Compliant Fax 717 558-7818 Attn M. Contact name at referring Board Phone Mailing Address Medical School Board Certified U.S. Yes Canada No Original Cert Date // International Specialty Recert Date // Board In what year were you first licensed In what state s have you held a license other than a training license State Name Active Active...

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