{
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "TWIN RIVERS PHYSICAL THERAPY, LLC",
"LastName": null,
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"MiddleName": null,
"NamePrefix": null,
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"FirstLineMailingAddress": "725 6TH ST",
"SecondLineMailingAddress": "STE 101",
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"MailingAddressStateName": "WA",
"MailingAddressPostalCode": "99403-2006",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "509-758-8510",
"MailingAddressFaxNumber": "509-751-9149",
"FirstLinePracticeLocationAddress": "725 6TH ST",
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"PracticeLocationAddressCityName": "CLARKSTON",
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"PracticeLocationAddressPostalCode": "99403-2006",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "509-758-8510",
"PracticeLocationAddressFaxNumber": "509-751-9149",
"EnumerationDate": "11/27/2006",
"LastUpdateDate": "12/17/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WAHLBERG",
"AuthorizedOfficialFirstName": "BRENT",
"AuthorizedOfficialMiddleName": "W",
"AuthorizedOfficialTitle": "PT OWNER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": "RPT",
"AuthorizedOfficialTelephoneNumber": "509-758-8510",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "225100000X",
"TaxonomyName": "Physical Therapist",
"LicenseNumber": "PT396",
"LicenseNumberStateCode": "ID",
"PrimaryTaxonomySwitch": "N"
},
{
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"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
]
}
}
}