{
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"FirstLineMailingAddress": "6321 N KEYSTONE AVE",
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"EnumerationDate": "08/13/2007",
"LastUpdateDate": "09/02/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": "04/15/2008",
"NPIReactivationDate": "05/20/2008",
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FORTUNATO",
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"Taxonomies": {
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},
{
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}
]
},
"HealthcareProviderTaxonomyGroups": {
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},
{
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"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}