{
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"MailingAddressFaxNumber": "912-225-3770",
"FirstLinePracticeLocationAddress": "124 SAVANNAH AVE STE 1C",
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"EnumerationDate": "09/14/2017",
"LastUpdateDate": "03/16/2023",
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WELCKER",
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}
},
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}
}