{
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"EIN": null,
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"OrgName": "REHABILITACION Y MEDICINA DEPORTIVA INC",
"LastName": null,
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"NameSuffix": null,
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"FirstLineMailingAddress": "PO BOX 2500",
"SecondLineMailingAddress": "PMB 122",
"MailingAddressCityName": "TRUJILLO ALTO",
"MailingAddressStateName": "PR",
"MailingAddressPostalCode": "00977-2500",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "787-276-7006",
"MailingAddressFaxNumber": "787-276-7030",
"FirstLinePracticeLocationAddress": "AVE FRAGOJO #4ES12",
"SecondLinePracticeLocationAddress": "VILLA FONTANA",
"PracticeLocationAddressCityName": "CAROLINA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "787-276-7006",
"PracticeLocationAddressFaxNumber": "787-276-7030",
"EnumerationDate": "12/04/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "HERNANDEZ",
"AuthorizedOfficialFirstName": "MICHAEL",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "MD PARTNER VICE PRESIDENT",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Physical Therapist",
"LicenseNumber": "14361",
"LicenseNumberStateCode": "PR",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"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."
}
}
}
}