{
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"FirstLineMailingAddress": "1701 W CHERRY BUD DR APT 6210",
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"MailingAddressCityName": "PEORIA",
"MailingAddressStateName": "IL",
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"FirstLinePracticeLocationAddress": "518 W ROMERO B GARRET AVE",
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"PracticeLocationAddressCityName": "POERIA",
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"EnumerationDate": "04/19/2018",
"LastUpdateDate": "04/19/2018",
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"GenderCode": "M",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Physical Therapist",
"LicenseNumber": "070.023543",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"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."
}
}
}
}