{
"Npi": {
"NPI": "1174039846",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "FEDERAL COMP AND WELLNESS SAN ANTONIO, PLLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "18817 HEATHERWILDE BLVD",
"SecondLineMailingAddress": "STE 150",
"MailingAddressCityName": "PFLUGERVILLE",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "78660-2543",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "512-523-4878",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "2515 BABCOCK RD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SAN ANTONIO",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "78229-4807",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "210-910-4949",
"PracticeLocationAddressFaxNumber": "512-870-9770",
"EnumerationDate": "12/18/2017",
"LastUpdateDate": "04/29/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MARTENS",
"AuthorizedOfficialFirstName": "THOMAS",
"AuthorizedOfficialMiddleName": "EDWARD",
"AuthorizedOfficialTitle": "OWNER/CEO",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DO",
"AuthorizedOfficialTelephoneNumber": "512-523-4878",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261Q00000X",
"TaxonomyName": "Clinic/Center",
"LicenseNumber": "L8125",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207QA0505X",
"TaxonomyName": "Adult Medicine Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}