{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "BOLINGBROOK WELLNESS",
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"FirstLineMailingAddress": "550 E BOUGHTON RD",
"SecondLineMailingAddress": "SUITE 205",
"MailingAddressCityName": "BOLINGBROOK",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "60440-2100",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "630-410-2620",
"MailingAddressFaxNumber": "630-410-2623",
"FirstLinePracticeLocationAddress": "550 E BOUGHTON RD",
"SecondLinePracticeLocationAddress": "SUITE 205",
"PracticeLocationAddressCityName": "BOLINGBROOK",
"PracticeLocationAddressStateName": "IL",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "630-410-2620",
"PracticeLocationAddressFaxNumber": "630-410-2623",
"EnumerationDate": "03/05/2015",
"LastUpdateDate": "03/05/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SPATHARAKIS",
"AuthorizedOfficialFirstName": "GUS",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CLINIC DIRECTOR",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.C.",
"AuthorizedOfficialTelephoneNumber": "630-410-2620",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "111N00000X",
"TaxonomyName": "Chiropractor",
"LicenseNumber": "038.012495",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}