{
"Npi": {
"NPI": "1194121210",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "BOOMER RIDE",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "724 5TH ST W APT B",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "HASTINGS",
"MailingAddressStateName": "MN",
"MailingAddressPostalCode": "55033-1745",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "651-263-0189",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "724 5TH ST W APT B",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "HASTINGS",
"PracticeLocationAddressStateName": "MN",
"PracticeLocationAddressPostalCode": "55033-1745",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "651-263-0189",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/17/2014",
"LastUpdateDate": "11/17/2014",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "HOWARD",
"AuthorizedOfficialFirstName": "LESLIE",
"AuthorizedOfficialMiddleName": "DEAN",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "651-263-0189",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "347C00000X",
"TaxonomyName": "Private Vehicle",
"LicenseNumber": "C893012006120",
"LicenseNumberStateCode": "MN",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}