{
"Npi": {
"NPI": "1083358378",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "RENEWED HEALTH AND 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": "615 W JOHNSON AVE STE 202-1061",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CHESHIRE",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06410-4531",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "475-377-0887",
"MailingAddressFaxNumber": "806-454-5698",
"FirstLinePracticeLocationAddress": "615 W JOHNSON AVE STE 202-1061",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CHESHIRE",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06410-4531",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "475-377-0887",
"PracticeLocationAddressFaxNumber": "806-454-5698",
"EnumerationDate": "04/23/2022",
"LastUpdateDate": "08/04/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LUGO MENDEZ",
"AuthorizedOfficialFirstName": "AWILDA",
"AuthorizedOfficialMiddleName": "ALTAGRACIA",
"AuthorizedOfficialTitle": "MANAGING MEMBER",
"AuthorizedOfficialNamePrefix": "MS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "FNP",
"AuthorizedOfficialTelephoneNumber": "203-510-1187",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "363LF0000X",
"TaxonomyName": "Family Nurse Practitioner",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}