{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "BRECKENRIDGE REHABILITATION SPECIALISTS LLC",
"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"OtherOrgNameTypeCode": "6",
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"FirstLineMailingAddress": "106 N. FRENCH ST PO BOX 4869",
"SecondLineMailingAddress": "SUITE 250",
"MailingAddressCityName": "BRECKENRIDGE",
"MailingAddressStateName": "CO",
"MailingAddressPostalCode": "80424-4869",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "970-485-3421",
"MailingAddressFaxNumber": "970-453-1960",
"FirstLinePracticeLocationAddress": "106 N. FRENCH ST",
"SecondLinePracticeLocationAddress": "SUITE 250",
"PracticeLocationAddressCityName": "BRECKENRIDGE",
"PracticeLocationAddressStateName": "CO",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "970-485-3421",
"PracticeLocationAddressFaxNumber": "970-453-1960",
"EnumerationDate": "10/16/2014",
"LastUpdateDate": "10/27/2014",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WELCH",
"AuthorizedOfficialFirstName": "JUSTIN",
"AuthorizedOfficialMiddleName": "MICHAEL",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PT, DPT",
"AuthorizedOfficialTelephoneNumber": "970-485-3421",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Specialist",
"LicenseNumber": "0010078",
"LicenseNumberStateCode": "CO",
"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."
}
}
}
}