{
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"FirstLineMailingAddress": "10300 FOREST HILL BLVD",
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"MailingAddressCityName": "WELLINGTON",
"MailingAddressStateName": "FL",
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"MailingAddressCountryCode": "US",
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"FirstLinePracticeLocationAddress": "10300 FOREST HILL BLVD STE 270",
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"PracticeLocationAddressCityName": "WELLINGTON",
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"EnumerationDate": "06/08/2017",
"LastUpdateDate": "10/26/2022",
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "METELLUS",
"AuthorizedOfficialFirstName": "EVELYN",
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"AuthorizedOfficialTitle": "PRESIDENT",
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"AuthorizedOfficialCredential": "HAIR LOSS SPECIALIST",
"AuthorizedOfficialTelephoneNumber": "561-574-0597",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1744P3200X",
"TaxonomyName": "Prosthetics Case Management",
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"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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}
}
}
}