{
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"FirstLineMailingAddress": "844 N STONE ST STE 206",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "DELAND",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32720-3208",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "386-736-7192",
"MailingAddressFaxNumber": "386-736-8520",
"FirstLinePracticeLocationAddress": "844 N STONE ST STE 206",
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"PracticeLocationAddressCityName": "DELAND",
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"PracticeLocationAddressCountryCode": "US",
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"PracticeLocationAddressFaxNumber": "386-736-8520",
"EnumerationDate": "04/06/2012",
"LastUpdateDate": "12/30/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "TIMKO",
"AuthorizedOfficialFirstName": "JAMES",
"AuthorizedOfficialMiddleName": "ROBERT",
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"AuthorizedOfficialCredential": "CCC-A",
"AuthorizedOfficialTelephoneNumber": "386-736-7192",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "231HA2500X",
"TaxonomyName": "Assistive Technology Supplier Audiologist",
"LicenseNumber": "AY393",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"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."
}
}
}
}