{
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"LastName": null,
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"NamePrefix": null,
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"OtherCredential": null,
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"FirstLineMailingAddress": "1400 131ST AVE NE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BLAINE",
"MailingAddressStateName": "MN",
"MailingAddressPostalCode": "55449-4124",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "763-862-7100",
"MailingAddressFaxNumber": "763-862-7077",
"FirstLinePracticeLocationAddress": "1400 131ST AVE NE",
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"PracticeLocationAddressCityName": "BLAINE",
"PracticeLocationAddressStateName": "MN",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "763-862-7100",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "04/17/2009",
"LastUpdateDate": "05/01/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FORS",
"AuthorizedOfficialFirstName": "GREGORY",
"AuthorizedOfficialMiddleName": "CHARLES",
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"AuthorizedOfficialCredential": "DC",
"AuthorizedOfficialTelephoneNumber": "763-862-7100",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Clinic/Center",
"LicenseNumber": "1836",
"LicenseNumberStateCode": "MN",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}