{
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"EIN": null,
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"IsOrgSubpart": "N",
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"ParentOrgTIN": null,
"OrgName": "VICTORY PHYSICAL THERAPY AND WELLNESS SPECIALISTS",
"LastName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "PO BOX 3497",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "STURTEVANT",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "53177-0300",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "877-552-2996",
"MailingAddressFaxNumber": "886-245-8064",
"FirstLinePracticeLocationAddress": "3908 HALL AVE",
"SecondLinePracticeLocationAddress": "SUITE A",
"PracticeLocationAddressCityName": "MARINETTE",
"PracticeLocationAddressStateName": "WI",
"PracticeLocationAddressPostalCode": "54143-1018",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "715-732-4127",
"PracticeLocationAddressFaxNumber": "715-732-4137",
"EnumerationDate": "08/16/2006",
"LastUpdateDate": "03/10/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BRIAND",
"AuthorizedOfficialFirstName": "LARRY",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CO-OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PT, ATC",
"AuthorizedOfficialTelephoneNumber": "877-552-2996",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "225100000X",
"TaxonomyName": "Physical Therapist",
"LicenseNumber": "9832024",
"LicenseNumberStateCode": "WI",
"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."
}
}
}
}