{
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"EIN": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "21834 139TH AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SPRINGFIELD GARDENS",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "11413-2652",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "718-238-9300",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "21834 139 AVENUE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SPRINGFIELD GARDENS",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "11413",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "718-238-9300",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "08/22/2017",
"LastUpdateDate": "07/21/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "IGBANUGO",
"AuthorizedOfficialFirstName": "NELSON",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "ADMINISTRATOR",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "917-771-5292",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "251E00000X",
"TaxonomyName": "Home Health Agency",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}