{
"Npi": {
"NPI": "1023556164",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "HEALTHSOURCE CHIROPRACTIC OF CHAMPAIGN, S.C.",
"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": "2003 ROUND BARN RD",
"SecondLineMailingAddress": "SUITE B",
"MailingAddressCityName": "CHAMPAIGN",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "61821-6827",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "217-281-0006",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "2003 ROUND BARN RD",
"SecondLinePracticeLocationAddress": "SUITE B",
"PracticeLocationAddressCityName": "CHAMPAIGN",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "61821-6827",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "217-281-0006",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "02/09/2017",
"LastUpdateDate": "01/16/2018",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MACKICHAN",
"AuthorizedOfficialFirstName": "CAMERON",
"AuthorizedOfficialMiddleName": "ROBERT",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.C.",
"AuthorizedOfficialTelephoneNumber": "217-281-0006",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261Q00000X",
"TaxonomyName": "Clinic/Center",
"LicenseNumber": "038.012800",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}