{
"Npi": {
"NPI": "1164963914",
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"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "NEW YORK WELLNESS,LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
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"OtherNamePrefix": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "11825 STATE ROUTE 40",
"SecondLineMailingAddress": "STE. #100",
"MailingAddressCityName": "DUNLAP",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "61525-8842",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "309-839-9943",
"MailingAddressFaxNumber": "309-839-9943",
"FirstLinePracticeLocationAddress": "9 E 45TH ST",
"SecondLinePracticeLocationAddress": "6TH FLOOR",
"PracticeLocationAddressCityName": "NEW YORK",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "10017-2425",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "212-401-0602",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "03/13/2017",
"LastUpdateDate": "03/20/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MOBILIA",
"AuthorizedOfficialFirstName": "NICK",
"AuthorizedOfficialMiddleName": "M",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.D.S",
"AuthorizedOfficialTelephoneNumber": "212-401-0602",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "043050",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}