{
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"EIN": null,
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"OrgName": "SPECTRUM FITNESS, LLC",
"LastName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "2300 NEW RD STE 103",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "NORTHFIELD",
"MailingAddressStateName": "NJ",
"MailingAddressPostalCode": "08225-1457",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "609-204-4849",
"MailingAddressFaxNumber": "609-653-1258",
"FirstLinePracticeLocationAddress": "2300 NEW RD STE 103",
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"PracticeLocationAddressCityName": "NORTHFIELD",
"PracticeLocationAddressStateName": "NJ",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "609-204-4849",
"PracticeLocationAddressFaxNumber": "609-383-8340",
"EnumerationDate": "06/18/2013",
"LastUpdateDate": "10/23/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BONCZEK",
"AuthorizedOfficialFirstName": "ANNETTE",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CO OWNER",
"AuthorizedOfficialNamePrefix": "MRS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PT",
"AuthorizedOfficialTelephoneNumber": "609-204-4849",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "174400000X",
"TaxonomyName": "Specialist",
"LicenseNumber": "40QA00696500",
"LicenseNumberStateCode": "NJ",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X 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."
}
}
}
}