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VETERINARY DEFENCE ASSOCIATION

NFP Reg no: 66926673

Mail to: 7911 Timbercreek Ln, North Charleston, SC 29418

Basic Information

Full Name

Email

Work Phone

Home Phone

Mobile

Fax

Physical Address

Mailing Address differs from Physical Address Yes No

Mailing Address

Qualifications

Veterinary School

Qualifications

Year of Qualification

Professional

State Veterinary Medical Board

State Veterinary Medical Board License Number

Practise Name/Place where relief service provided

Company Name (If Applicable)

Professional Activity

Small Animal %

Large Animal %

Equine %

Avian %

Exotics %

Other (please specify) %

Other

Total (needs to add up to 100)

Claims/ Board Complaints and Payment methods

Claims / Complaints Yes No

Names of other Veterinarians in Your Practice

Paypal