{
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"EIN": null,
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"FirstLineMailingAddress": "2486 N PONDEROSA DR",
"SecondLineMailingAddress": "STE D106",
"MailingAddressCityName": "CAMARILLO",
"MailingAddressStateName": "CA",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "805-484-5447",
"MailingAddressFaxNumber": "805-484-2158",
"FirstLinePracticeLocationAddress": "2486 N PONDEROSA DR",
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"PracticeLocationAddressCityName": "CAMARILLO",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "805-484-5447",
"PracticeLocationAddressFaxNumber": "805-484-2158",
"EnumerationDate": "09/19/2005",
"LastUpdateDate": "07/08/2007",
"NPIDeactivationReasonCode": null,
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"NPIReactivationDate": null,
"GenderCode": "M",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Physical Therapist",
"LicenseNumber": "PT005390",
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}