{
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"FirstLineMailingAddress": "1316 STEVENS AVE",
"SecondLineMailingAddress": "UNIT B",
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"MailingAddressPostalCode": "91776-4477",
"MailingAddressCountryCode": "US",
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"FirstLinePracticeLocationAddress": "1316 STEVENS AVE",
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"EnumerationDate": "08/24/2007",
"LastUpdateDate": "08/24/2007",
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"NPIReactivationDate": null,
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"AuthorizedOfficialLastName": "SO",
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"AuthorizedOfficialTitle": "REGISTER VASCULAR TECHNICIAN",
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"AuthorizedOfficialCredential": "R.V.T.",
"AuthorizedOfficialTelephoneNumber": "626-289-2720",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Vascular Sonography Radiologic Technologist",
"LicenseNumber": "109278",
"LicenseNumberStateCode": "CA",
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}
},
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}
}
}
}