{
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"EIN": null,
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"ParentOrgLBN": null,
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"OrgName": "BACK COUNTRY PHYSICAL THERAPY, LLC",
"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"FirstLineMailingAddress": "51 COFFEEN AVE.",
"SecondLineMailingAddress": "STE 101 PMB 286",
"MailingAddressCityName": "SHERIDAN",
"MailingAddressStateName": "WY",
"MailingAddressPostalCode": "82801-7004",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "307-336-7774",
"MailingAddressFaxNumber": "307-202-4643",
"FirstLinePracticeLocationAddress": "1262 W 5TH ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SHERIDAN",
"PracticeLocationAddressStateName": "WY",
"PracticeLocationAddressPostalCode": "82801-2702",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "307-336-7774",
"PracticeLocationAddressFaxNumber": "307-202-4643",
"EnumerationDate": "06/11/2015",
"LastUpdateDate": "02/14/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "JENKS",
"AuthorizedOfficialFirstName": "BRETT",
"AuthorizedOfficialMiddleName": "A",
"AuthorizedOfficialTitle": "OWNER/PHYSICAL THERAPIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PT, DPT, CERT. MDT",
"AuthorizedOfficialTelephoneNumber": "307-336-7774",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "225100000X",
"TaxonomyName": "Physical Therapist",
"LicenseNumber": "PT-1552",
"LicenseNumberStateCode": "WY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"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."
}
}
}
}