{
"Npi": {
"NPI": "1023731114",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SUPER SONIC HEALTH & WELLNESS, 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": "1053 W BLOOMINGTON DR S",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ST GEORGE",
"MailingAddressStateName": "UT",
"MailingAddressPostalCode": "84790-7567",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "520-265-6194",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1054 E RIVERSIDE DR STE 201",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "ST GEORGE",
"PracticeLocationAddressStateName": "UT",
"PracticeLocationAddressPostalCode": "84790-4829",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "435-688-8991",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "09/22/2022",
"LastUpdateDate": "09/22/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ST GEORGE",
"AuthorizedOfficialFirstName": "BARRETT",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER/OPERATOR",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "AU.D., PH.D.",
"AuthorizedOfficialTelephoneNumber": "520-265-6194",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QH0700X",
"TaxonomyName": "Hearing and Speech Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}