{
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"LastName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "PO BOX 1190",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SILVERDALE",
"MailingAddressStateName": "WA",
"MailingAddressPostalCode": "98383-1190",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": null,
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "16821 SE MCGILLIVRAY BLVD",
"SecondLinePracticeLocationAddress": "SUITE 204",
"PracticeLocationAddressCityName": "VANCOUVER",
"PracticeLocationAddressStateName": "WA",
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"PracticeLocationAddressTelephoneNumber": "360-433-9580",
"PracticeLocationAddressFaxNumber": "866-824-5107",
"EnumerationDate": "06/20/2016",
"LastUpdateDate": "06/20/2016",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BERGQUIST",
"AuthorizedOfficialFirstName": "KYLE",
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"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DC",
"AuthorizedOfficialTelephoneNumber": "206-713-4721",
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"Taxonomy": {
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"TaxonomyName": "Multi-Specialty Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}