{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "TRI-VISTA REHAB, INC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
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"OtherLastName": null,
"OtherFirstName": null,
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"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "90A CLARK BLVD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "TUPELO",
"MailingAddressStateName": "MS",
"MailingAddressPostalCode": "38804-2801",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "662-840-0535",
"MailingAddressFaxNumber": "662-842-7915",
"FirstLinePracticeLocationAddress": "90A CLARK BLVD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "TUPELO",
"PracticeLocationAddressStateName": "MS",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "662-840-0535",
"PracticeLocationAddressFaxNumber": "662-842-7915",
"EnumerationDate": "08/07/2012",
"LastUpdateDate": "09/26/2012",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BOUTIN",
"AuthorizedOfficialFirstName": "KEVIN",
"AuthorizedOfficialMiddleName": "TROY",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "OTR",
"AuthorizedOfficialTelephoneNumber": "662-840-0535",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "310400000X",
"TaxonomyName": "Assisted Living Facility",
"LicenseNumber": "PT4554",
"LicenseNumberStateCode": "MS",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}