{
"Npi": {
"NPI": "1306015086",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "IVANCICH PODIATRY SERVICES, INC.",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 660025",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ARCADIA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "91066-0025",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "626-401-2775",
"MailingAddressFaxNumber": "626-401-9826",
"FirstLinePracticeLocationAddress": "11800 VALLEY BLVD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "EL MONTE",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "91732-3040",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "626-401-2775",
"PracticeLocationAddressFaxNumber": "626-401-9826",
"EnumerationDate": "02/26/2008",
"LastUpdateDate": "09/11/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "IVANCICH",
"AuthorizedOfficialFirstName": "LARRY",
"AuthorizedOfficialMiddleName": "M.",
"AuthorizedOfficialTitle": "PODIATRIST",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.P.M.",
"AuthorizedOfficialTelephoneNumber": "626-401-2775",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "213E00000X",
"TaxonomyName": "Podiatrist",
"LicenseNumber": "E3249",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}