{
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"FirstLineMailingAddress": "2045 J B RILEY RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BURKBURNETT",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "76354-5754",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "432-425-7632",
"MailingAddressFaxNumber": "940-432-3449",
"FirstLinePracticeLocationAddress": "405 SE ACCESS RD",
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"PracticeLocationAddressCityName": "IOWA PARK",
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"EnumerationDate": "02/14/2012",
"LastUpdateDate": "12/29/2025",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "TEVENI",
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"AuthorizedOfficialTelephoneNumber": "432-425-7632",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Family Medicine Physician",
"LicenseNumber": "H2972",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}