{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "COUNTRY CLUB PHYSICAL THERAPY, LLC",
"LastName": null,
"FirstName": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 8838",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "NAPLES",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "34101-8838",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "239-280-1229",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "14529 INDIGO LAKES CIR",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "NAPLES",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "34119-4811",
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"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/28/2012",
"LastUpdateDate": "11/28/2012",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CROMBIE",
"AuthorizedOfficialFirstName": "PHILIP",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PHYSICAL THERAPIST/OWNER",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DPT",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Physical Therapist",
"LicenseNumber": "PT11581",
"LicenseNumberStateCode": "FL",
"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."
}
}
}
}