{
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"OrgName": "SUMMIT PHYSICAL THERAPY, PLLC",
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"FirstLineMailingAddress": "2219 COUNTY ROAD 220 STE 304",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MIDDLEBURG",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32068-7778",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "904-644-7722",
"MailingAddressFaxNumber": "904-637-1532",
"FirstLinePracticeLocationAddress": "2140 KINGSLEY AVE STE 11",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "ORANGE PARK",
"PracticeLocationAddressStateName": "FL",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "904-592-1036",
"PracticeLocationAddressFaxNumber": "904-637-1532",
"EnumerationDate": "02/28/2024",
"LastUpdateDate": "02/28/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "VOLLERTSEN",
"AuthorizedOfficialFirstName": "TARA",
"AuthorizedOfficialMiddleName": "REEVES",
"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialCredential": "PT",
"AuthorizedOfficialTelephoneNumber": "904-644-7722",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Physical Therapist",
"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."
}
}
}
}