{
"Npi": {
"NPI": "1235304924",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MOULTON OPTICAL DEPARTMENT",
"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": "5518 ELLSWORTH RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FORT SMITH",
"MailingAddressStateName": "AR",
"MailingAddressPostalCode": "72903-3222",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "479-646-3937",
"MailingAddressFaxNumber": "479-646-3605",
"FirstLinePracticeLocationAddress": "5518 ELLSWORTH RD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "FORT SMITH",
"PracticeLocationAddressStateName": "AR",
"PracticeLocationAddressPostalCode": "72903-3222",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "479-646-3937",
"PracticeLocationAddressFaxNumber": "479-646-3605",
"EnumerationDate": "04/24/2008",
"LastUpdateDate": "01/24/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MOULTON",
"AuthorizedOfficialFirstName": "EVERETT",
"AuthorizedOfficialMiddleName": "CROCKETT",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": "III",
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "479-646-3937",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "332H00000X",
"TaxonomyName": "Eyewear Supplier",
"LicenseNumber": "C4990",
"LicenseNumberStateCode": "AR",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}