{
"Npi": {
"NPI": "1154459949",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "BERKELEY WELLNESS ASSOCIATES",
"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": "1922 CAMBRIDGE DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CROFTON",
"MailingAddressStateName": "MD",
"MailingAddressPostalCode": "21114-1908",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "410-721-2714",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "3327 SUPERIOR LN",
"SecondLinePracticeLocationAddress": "SUITE 204",
"PracticeLocationAddressCityName": "BOWIE",
"PracticeLocationAddressStateName": "MD",
"PracticeLocationAddressPostalCode": "20715-1922",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "301-860-0288",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "03/01/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BERKELEY",
"AuthorizedOfficialFirstName": "GLENN",
"AuthorizedOfficialMiddleName": "BRADFORD",
"AuthorizedOfficialTitle": "CEO",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.C",
"AuthorizedOfficialTelephoneNumber": "240-476-5684",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QH0100X",
"TaxonomyName": "Health Service Clinic/Center",
"LicenseNumber": "02187",
"LicenseNumberStateCode": "MD",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}