{
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"FirstLineMailingAddress": "P O BOX 8203",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WARNER ROBINS",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "31095-8203",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "478-783-3610",
"MailingAddressFaxNumber": "478-783-3611",
"FirstLinePracticeLocationAddress": "2809 PINE ST",
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"PracticeLocationAddressCityName": "UNADILLA",
"PracticeLocationAddressStateName": "GA",
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"PracticeLocationAddressTelephoneNumber": "478-355-3000",
"PracticeLocationAddressFaxNumber": "478-355-3001",
"EnumerationDate": "11/29/2019",
"LastUpdateDate": "11/18/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "IBEZI-ENENDU",
"AuthorizedOfficialFirstName": "ALEXANDER",
"AuthorizedOfficialMiddleName": "C",
"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DO",
"AuthorizedOfficialTelephoneNumber": "404-702-9466",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207Q00000X",
"TaxonomyName": "Family Medicine Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"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."
}
}
}
}