{
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"OrgName": "TRISTATE PROFESSIONAL SERVICES INC",
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"FirstLineMailingAddress": "508 E JACKSON ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "RIVERTON",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "62561-8064",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "217-259-8461",
"MailingAddressFaxNumber": "217-522-4861",
"FirstLinePracticeLocationAddress": "2760 N DIRKSEN PKWY",
"SecondLinePracticeLocationAddress": "ATTN: WALMART VISION CTR",
"PracticeLocationAddressCityName": "SPRINGFIELD",
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"PracticeLocationAddressTelephoneNumber": "217-522-4396",
"PracticeLocationAddressFaxNumber": "217-522-4861",
"EnumerationDate": "12/16/2009",
"LastUpdateDate": "12/16/2009",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "EDWARDS",
"AuthorizedOfficialFirstName": "ROBERT",
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"AuthorizedOfficialTelephoneNumber": "217-259-8461",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Optometrist",
"LicenseNumber": "046006399",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}