{
"Npi": {
"NPI": "1154594190",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SIOC@BAY ST OPTICAL PAVILION",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "664 BAY ST",
"SecondLineMailingAddress": "OPTICAL",
"MailingAddressCityName": "STATEN ISLAND",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "10304-3829",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": null,
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "664 BAY ST",
"SecondLinePracticeLocationAddress": "OPTICAL",
"PracticeLocationAddressCityName": "STATEN ISLAND",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "10304-3829",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "718-727-5678",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "04/10/2008",
"LastUpdateDate": "04/10/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "POWELL RIVERS",
"AuthorizedOfficialFirstName": "CAROLYN",
"AuthorizedOfficialMiddleName": "ROSEMARY",
"AuthorizedOfficialTitle": "PRINCIPLE",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "OD",
"AuthorizedOfficialTelephoneNumber": "718-727-5678",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "152W00000X",
"TaxonomyName": "Optometrist",
"LicenseNumber": "TUV004813-1",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}