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1714 SW 17th St, Ocala, FL 34471 Toll Free Phone: 8336827818 Phone: 3522749565 Fax: 8889785541 Headfirst: NPI1952763971 Tax ID#: 811981130STAT PATIENT NAME:DATE:PHONE:D.O.B. DIAGNOSIS/ICD 10: IF CONTRASTED:

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