{
"Npi": {
"NPI": "1104943729",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MEDICAL VISION ASSOCIATES OF NORTHPORT",
"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": "3101 MAIN AVE",
"SecondLineMailingAddress": "SUITE C",
"MailingAddressCityName": "NORTHPORT",
"MailingAddressStateName": "AL",
"MailingAddressPostalCode": "35476-3111",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "205-330-0705",
"MailingAddressFaxNumber": "205-330-1750",
"FirstLinePracticeLocationAddress": "3101 MAIN AVE",
"SecondLinePracticeLocationAddress": "SUITE C",
"PracticeLocationAddressCityName": "NORTHPORT",
"PracticeLocationAddressStateName": "AL",
"PracticeLocationAddressPostalCode": "35476-3111",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "205-330-0705",
"PracticeLocationAddressFaxNumber": "205-330-1750",
"EnumerationDate": "03/26/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SUMNER",
"AuthorizedOfficialFirstName": "LARRY",
"AuthorizedOfficialMiddleName": "HUGH",
"AuthorizedOfficialTitle": "OPTICIAN",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "205-330-0705",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "332H00000X",
"TaxonomyName": "Eyewear Supplier",
"LicenseNumber": "4669",
"LicenseNumberStateCode": "AL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}