{
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"EIN": null,
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"IsOrgSubpart": "N",
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"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"OtherLastName": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 875",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BUENA VISTA",
"MailingAddressStateName": "CO",
"MailingAddressPostalCode": "81211-0875",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "832-622-3766",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "18065 RIO HONDO DR",
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"PracticeLocationAddressCityName": "BUENA VISTA",
"PracticeLocationAddressStateName": "CO",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "832-622-3766",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "06/26/2011",
"LastUpdateDate": "06/26/2011",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CARROLL",
"AuthorizedOfficialFirstName": "DONALD",
"AuthorizedOfficialMiddleName": "CHRISTOPHER",
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"AuthorizedOfficialCredential": "MDIV",
"AuthorizedOfficialTelephoneNumber": "832-622-3766",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "251V00000X",
"TaxonomyName": "Voluntary or Charitable Agency",
"LicenseNumber": "32043043572",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}