{
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"FirstLineMailingAddress": "3035 GENESEE ST",
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"FirstLinePracticeLocationAddress": "1779 ORCHARD PARK RD",
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"EnumerationDate": "03/29/2011",
"LastUpdateDate": "09/17/2025",
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "JOBA",
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"AuthorizedOfficialTelephoneNumber": "716-947-2462",
"Taxonomies": {
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{
"TaxonomyCode": "332H00000X",
"TaxonomyName": "Eyewear Supplier",
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},
{
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}
]
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}