{
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"EIN": null,
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"FirstLineMailingAddress": "810 E CHAPMAN AVE",
"SecondLineMailingAddress": "SUITE C",
"MailingAddressCityName": "FULLERTON",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92831-3850",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "714-626-0417",
"MailingAddressFaxNumber": "714-626-0319",
"FirstLinePracticeLocationAddress": "810 E CHAPMAN AVE",
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"PracticeLocationAddressCityName": "FULLERTON",
"PracticeLocationAddressStateName": "CA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "714-626-0417",
"PracticeLocationAddressFaxNumber": "714-626-0319",
"EnumerationDate": "07/26/2007",
"LastUpdateDate": "08/01/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Prosthetic/Orthotic Supplier",
"LicenseNumber": "CPO 02709",
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}