{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"LastName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "6520 WEST BLVD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "LOS ANGELES",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "90043-4311",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "909-230-1455",
"MailingAddressFaxNumber": "323-210-3790",
"FirstLinePracticeLocationAddress": "6520 WEST BLVD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "LOS ANGELES",
"PracticeLocationAddressStateName": "CA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "323-753-1354",
"PracticeLocationAddressFaxNumber": "323-210-3790",
"EnumerationDate": "08/23/2016",
"LastUpdateDate": "02/11/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ROBERTS",
"AuthorizedOfficialFirstName": "JASON",
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"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "909-230-1455",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "314000000X",
"TaxonomyName": "Skilled Nursing Facility",
"LicenseNumber": "910000066",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}