{
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"IsOrgSubpart": "N",
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"ParentOrgTIN": null,
"OrgName": "FREDERICK CUSTOMEYEZ PROSTHETICS LLC",
"LastName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "9278 PARADISE DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PANAMA CITY BEACH",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32413-9625",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "401-584-3939",
"MailingAddressFaxNumber": "216-678-9186",
"FirstLinePracticeLocationAddress": "1422 EUCLID AVE",
"SecondLinePracticeLocationAddress": "SUITE 802",
"PracticeLocationAddressCityName": "CLEVELAND",
"PracticeLocationAddressStateName": "OH",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "401-584-3939",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/26/2016",
"LastUpdateDate": "07/03/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FREDERICK",
"AuthorizedOfficialFirstName": "MELISSA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OCULARIST/OWNER",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "401-584-3939",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "156FX1700X",
"TaxonomyName": "Ocularist",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "335E00000X",
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"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"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."
}
}
}
}