{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "AMWALLACE, LLC",
"LastName": null,
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"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"FirstLineMailingAddress": "3032 N EASTMAN RD STE 100",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "LONGVIEW",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "75605-5024",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "903-663-2020",
"MailingAddressFaxNumber": "903-663-2353",
"FirstLinePracticeLocationAddress": "3032 N EASTMAN RD STE 100",
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"PracticeLocationAddressCityName": "LONGVIEW",
"PracticeLocationAddressStateName": "TX",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "903-663-2020",
"PracticeLocationAddressFaxNumber": "903-663-2353",
"EnumerationDate": "08/15/2011",
"LastUpdateDate": "03/25/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WALLACE",
"AuthorizedOfficialFirstName": "AUGUST",
"AuthorizedOfficialMiddleName": "MICHAEL",
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"AuthorizedOfficialNamePrefix": "MR.",
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"AuthorizedOfficialCredential": "OD",
"AuthorizedOfficialTelephoneNumber": "903-663-2020",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "152W00000X",
"TaxonomyName": "Optometrist",
"LicenseNumber": "T07660",
"LicenseNumberStateCode": "TX",
"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."
}
}
}
}