{
"Npi": {
"NPI": "1386309276",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MEDICAL FITNESS CLINIC OF KERRVILLE",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1007 RIVER TRAIL RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PIPE CREEK",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "78063-5979",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "210-569-4129",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1337 BANDERA HWY",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "KERRVILLE",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "78028-9555",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "210-569-4129",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/04/2021",
"LastUpdateDate": "11/10/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BLACK",
"AuthorizedOfficialFirstName": "BYRON",
"AuthorizedOfficialMiddleName": "KEITH",
"AuthorizedOfficialTitle": "MANAGER/OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PH.D, CEP",
"AuthorizedOfficialTelephoneNumber": "210-569-4129",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "224Y00000X",
"TaxonomyName": "Clinical Exercise Physiologist",
"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."
}
}
}
}