{
"Npi": {
"NPI": "1174188239",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SYNTHESIS RECOVERY LLC",
"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": "2238 KIRSTEN LEE DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WESTLAKE VILLAGE",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "91361-5564",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "310-498-3626",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "5498 BLACKOAK WAY",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SAN JOSE",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "95129-3110",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "833-338-1373",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/04/2019",
"LastUpdateDate": "05/22/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "VIDOV",
"AuthorizedOfficialFirstName": "SERGEI",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CEO",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "310-498-3626",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "324500000X",
"TaxonomyName": "Substance Abuse Rehabilitation Facility",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}