{
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"FirstLineMailingAddress": "315 E STE 202",
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"MailingAddressCityName": "WATERLOO",
"MailingAddressStateName": "IA",
"MailingAddressPostalCode": "50703",
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"FirstLinePracticeLocationAddress": "3158 SCANLON FARMS RD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CORALVILLE",
"PracticeLocationAddressStateName": "IA",
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"PracticeLocationAddressTelephoneNumber": "520-302-9943",
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"EnumerationDate": "01/05/2023",
"LastUpdateDate": "01/05/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FORCHU",
"AuthorizedOfficialFirstName": "JERRY",
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"AuthorizedOfficialTitle": "COO",
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"AuthorizedOfficialTelephoneNumber": "520-302-9943",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Attendant Care Provider",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}