{
"Npi": {
"NPI": "1275033078",
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"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "KORU PHYSICAL THERAPY AND WELLNESS, PLLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"OtherLastName": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "14 LEONARD ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PORTLAND",
"MailingAddressStateName": "ME",
"MailingAddressPostalCode": "04103-2513",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "207-712-2222",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "619 BRIGHTON AVE # 101",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "PORTLAND",
"PracticeLocationAddressStateName": "ME",
"PracticeLocationAddressPostalCode": "04102-2323",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "207-358-8161",
"PracticeLocationAddressFaxNumber": "207-352-5111",
"EnumerationDate": "02/19/2018",
"LastUpdateDate": "02/19/2018",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "POOLE",
"AuthorizedOfficialFirstName": "ALLISON",
"AuthorizedOfficialMiddleName": "RENA LAMARRE",
"AuthorizedOfficialTitle": "MANAGER, OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PT",
"AuthorizedOfficialTelephoneNumber": "207-358-8161",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QP2000X",
"TaxonomyName": "Physical Therapy Clinic/Center",
"LicenseNumber": "PT3294",
"LicenseNumberStateCode": "ME",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}