{
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"FirstLineMailingAddress": "1132 MADISON ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BEAVER DAM",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "53916",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "920-631-7031",
"MailingAddressFaxNumber": "920-631-7031",
"FirstLinePracticeLocationAddress": "1132 MADISON ST",
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"PracticeLocationAddressCityName": "BEAVER DAM",
"PracticeLocationAddressStateName": "WI",
"PracticeLocationAddressPostalCode": "53916-2628",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "920-631-7031",
"PracticeLocationAddressFaxNumber": "920-631-7031",
"EnumerationDate": "01/15/2016",
"LastUpdateDate": "07/21/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CHAMPEAU",
"AuthorizedOfficialFirstName": "DEBRA",
"AuthorizedOfficialMiddleName": "JEAN",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "MISS",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "920-631-7031",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Exclusive Provider Organization",
"LicenseNumber": null,
"LicenseNumberStateCode": "WI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}