{
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"FirstLineMailingAddress": "1616 CONCIERGE BLVD FL 1",
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"MailingAddressFaxNumber": "386-401-2385",
"FirstLinePracticeLocationAddress": "1616 CONCIERGE BLVD FL 1",
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"PracticeLocationAddressCityName": "DAYTONA BEACH",
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"EnumerationDate": "02/17/2026",
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"NPIDeactivationReasonCode": null,
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WALLACE",
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"Taxonomies": {
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"PrimaryTaxonomySwitch": "Y"
}
},
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}
}