{
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"EIN": null,
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"Credential": "D.C. C.C.S.P",
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"FirstLineMailingAddress": "28000 S WESTERN AVE UNIT 227",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SAN PEDRO",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "90732-1204",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "310-684-1807",
"MailingAddressFaxNumber": "310-684-1607",
"FirstLinePracticeLocationAddress": "1423 W 8TH ST",
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"PracticeLocationAddressCityName": "SAN PEDRO",
"PracticeLocationAddressStateName": "CA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "310-684-1807",
"PracticeLocationAddressFaxNumber": "310-684-1607",
"EnumerationDate": "01/22/2015",
"LastUpdateDate": "10/05/2022",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
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"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "111N00000X",
"TaxonomyName": "Chiropractor",
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"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "111NS0005X",
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}
]
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}