{
"Npi": {
"NPI": "1013574532",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "GREEN HEALTHCARE CLINIC LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "825 WOODLEA RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "KANKAKEE",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "60901-8199",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "815-937-0552",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "4425 W 63RD ST STE 204",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CHICAGO",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "60629-5565",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "888-876-7012",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/20/2019",
"LastUpdateDate": "05/20/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GREEN",
"AuthorizedOfficialFirstName": "JACINTA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER/PHYSICIAN",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "815-937-0552",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207RC0000X",
"TaxonomyName": "Cardiovascular Disease 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."
}
}
}
}