{
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"FirstLineMailingAddress": "PO BOX 3497",
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"MailingAddressCityName": "STURTEVANT",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "53177-3497",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "877-552-2996",
"MailingAddressFaxNumber": "866-245-8064",
"FirstLinePracticeLocationAddress": "110 E 10TH ST",
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"PracticeLocationAddressCityName": "KEWANEE",
"PracticeLocationAddressStateName": "IL",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "309-852-2200",
"PracticeLocationAddressFaxNumber": "309-852-2402",
"EnumerationDate": "08/21/2006",
"LastUpdateDate": "11/07/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DEBORD",
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"AuthorizedOfficialCredential": "PT, MS, ATC, SCS",
"AuthorizedOfficialTelephoneNumber": "309-852-2200",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Physical Therapist",
"LicenseNumber": "070009875",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}