{
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"LastName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "405 HERON DRIVE",
"SecondLineMailingAddress": "SUITE 200",
"MailingAddressCityName": "SWEDESBORO",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "800-331-8272",
"MailingAddressFaxNumber": "856-491-4365",
"FirstLinePracticeLocationAddress": "7631 E INDIAN SCHOOL ROAD",
"SecondLinePracticeLocationAddress": "SUITE 105",
"PracticeLocationAddressCityName": "SCOTTSDALE",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "800-331-8272",
"PracticeLocationAddressFaxNumber": "856-491-4365",
"EnumerationDate": "12/05/2006",
"LastUpdateDate": "05/27/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BERNAL-ANGEL",
"AuthorizedOfficialFirstName": "ALEJANDRO",
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"AuthorizedOfficialTitle": "CHIEF EXECUTIVE OFFICER, SECRETARY",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "973-307-7154",
"Taxonomies": {
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{
"TaxonomyCode": "333600000X",
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"LicenseNumber": "NP000022",
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},
{
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},
{
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"LicenseNumberStateCode": "AZ",
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}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}