{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "CHEBOYGAN LIFE SUPPORT SYSTEMS INC",
"LastName": null,
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"NamePrefix": null,
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"Credential": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "536 RIGGS DR",
"SecondLineMailingAddress": "P.O. BOX 105",
"MailingAddressCityName": "CHEBOYGAN",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "49721-1063",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "231-627-9348",
"MailingAddressFaxNumber": "231-627-1658",
"FirstLinePracticeLocationAddress": "536 RIGGS DR",
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"PracticeLocationAddressCityName": "CHEBOYGAN",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "231-627-9348",
"PracticeLocationAddressFaxNumber": "231-627-1658",
"EnumerationDate": "07/22/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "HYDE",
"AuthorizedOfficialFirstName": "DALLAS",
"AuthorizedOfficialMiddleName": "LEE",
"AuthorizedOfficialTitle": "DIRECTOR OF CLSS",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": "I",
"AuthorizedOfficialCredential": "PARAMEDIC",
"AuthorizedOfficialTelephoneNumber": "231-627-9348",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3416L0300X",
"TaxonomyName": "Land Ambulance",
"LicenseNumber": "161003",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}