{
"Npi": {
"NPI": "1083964357",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "RENALIFE, PSC",
"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": "PO BOX 1947",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CAGUAS",
"MailingAddressStateName": "PR",
"MailingAddressPostalCode": "00726-1947",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "787-224-0499",
"MailingAddressFaxNumber": "787-687-7639",
"FirstLinePracticeLocationAddress": "HOSPITAL AUXILIO MUTUO",
"SecondLinePracticeLocationAddress": "AVE PONCE DE LEON PDA 37 1/2",
"PracticeLocationAddressCityName": "SAN JUAN",
"PracticeLocationAddressStateName": "PR",
"PracticeLocationAddressPostalCode": "00919",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "787-458-2000",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "09/14/2012",
"LastUpdateDate": "06/25/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MIRANDA TIRADO",
"AuthorizedOfficialFirstName": "GLENDA",
"AuthorizedOfficialMiddleName": "MICHELLE",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "787-224-0499",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207RN0300X",
"TaxonomyName": "Nephrology Physician",
"LicenseNumber": "17265",
"LicenseNumberStateCode": "PR",
"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."
}
}
}
}