{
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"EIN": null,
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"FirstLineMailingAddress": "575 RIVERGATE UNIT 105",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "DURANGO",
"MailingAddressStateName": "CO",
"MailingAddressPostalCode": "81301-7490",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "970-259-3154",
"MailingAddressFaxNumber": "970-828-1666",
"FirstLinePracticeLocationAddress": "1440 BOISE AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "LOVELAND",
"PracticeLocationAddressStateName": "CO",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "970-278-1440",
"PracticeLocationAddressFaxNumber": "970-776-8067",
"EnumerationDate": "06/01/2018",
"LastUpdateDate": "06/01/2018",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "STEVENSON",
"AuthorizedOfficialFirstName": "ROBIN",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CREDENTIALING SPECIALIST",
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"AuthorizedOfficialTelephoneNumber": "480-832-1546",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Durable Medical Equipment & Medical Supplies",
"LicenseNumber": "14691",
"LicenseNumberStateCode": "CO",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}