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      Mar 1, 2009  $40.00
     

      Feb 1, 2009  $100.00
     

      Jan 1, 2009  $7.00
     
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Richmond,IN 47374
(765) 935-8895

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Patient ID PatientMedicalRecordNumber First Name Last Name Birth Date PatientServiceBeginDate PatientServiceEndDate AdditionalInfo1 Additional Info 2 Additional Info 3 Additional Info 4 Additional Info 5 Additional Info 6 Amount
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