{
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"EIN": null,
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"ParentOrgLBN": null,
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"LastName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "108 PARK PLACE BLVD STE C",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "DAVENPORT",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33837-6877",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "863-422-1737",
"MailingAddressFaxNumber": "407-681-4603",
"FirstLinePracticeLocationAddress": "108 PARK PLACE BLVD",
"SecondLinePracticeLocationAddress": "SUITE C",
"PracticeLocationAddressCityName": "DAVENPORT",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "863-422-1737",
"PracticeLocationAddressFaxNumber": "407-681-4603",
"EnumerationDate": "08/24/2017",
"LastUpdateDate": "07/21/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "HILL",
"AuthorizedOfficialFirstName": "NATHAN",
"AuthorizedOfficialMiddleName": "B",
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"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": "MD",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "332B00000X",
"TaxonomyName": "Durable Medical Equipment & Medical Supplies",
"LicenseNumber": null,
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}