{
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"FirstLineMailingAddress": "4557 WENDEN LN",
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"FirstLinePracticeLocationAddress": "4180 PROVIDENCE RD STE 107",
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"EnumerationDate": "08/08/2018",
"LastUpdateDate": "11/04/2024",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
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"AuthorizedOfficialLastName": "KOPACH",
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"AuthorizedOfficialCredential": "P.T.",
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"Taxonomies": {
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"TaxonomyName": "Physical Therapy Clinic/Center",
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"PrimaryTaxonomySwitch": "Y"
}
},
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}
}