{
"Npi": {
"NPI": "1003408857",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "THE MINNESOTA KETAMINE AND WELLNESS INSTITUTE PA",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "9325 UPLAND LN N STE 370",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MAPLE GROVE",
"MailingAddressStateName": "MN",
"MailingAddressPostalCode": "55369-4463",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "612-394-8717",
"MailingAddressFaxNumber": "763-432-5721",
"FirstLinePracticeLocationAddress": "9325 UPLAND LN N STE 370",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MAPLE GROVE",
"PracticeLocationAddressStateName": "MN",
"PracticeLocationAddressPostalCode": "55369-4463",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "612-394-8717",
"PracticeLocationAddressFaxNumber": "763-432-5721",
"EnumerationDate": "02/03/2021",
"LastUpdateDate": "08/20/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "HATCHER",
"AuthorizedOfficialFirstName": "CHRISTENA",
"AuthorizedOfficialMiddleName": "REGENA",
"AuthorizedOfficialTitle": "CFO",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "CRNA",
"AuthorizedOfficialTelephoneNumber": "612-394-8717",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QI0500X",
"TaxonomyName": "Infusion Therapy Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM0850X",
"TaxonomyName": "Adult Mental Health Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM1300X",
"TaxonomyName": "Multi-Specialty Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207L00000X",
"TaxonomyName": "Anesthesiology Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}