{
"Npi": {
"NPI": "1184800955",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "FOWLER SPORTS MEDICINE AND HEALTH PROMOTION",
"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": "2303 IRA E WOODS AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GRAPEVINE",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "76051-3926",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "817-488-0885",
"MailingAddressFaxNumber": "817-424-1234",
"FirstLinePracticeLocationAddress": "2303 IRA E WOODS AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "GRAPEVINE",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "76051-3926",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "817-488-0885",
"PracticeLocationAddressFaxNumber": "817-424-1234",
"EnumerationDate": "01/11/2008",
"LastUpdateDate": "01/11/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FOWLER",
"AuthorizedOfficialFirstName": "ROBERT",
"AuthorizedOfficialMiddleName": "WESLEY",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "817-488-0885",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "302F00000X",
"TaxonomyName": "Exclusive Provider Organization",
"LicenseNumber": "H5707",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}