{
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"EIN": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "706 SUGAR MAPLE CT",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FOUNTAIN INN",
"MailingAddressStateName": "SC",
"MailingAddressPostalCode": "29644-2144",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "864-483-0601",
"MailingAddressFaxNumber": "864-288-4608",
"FirstLinePracticeLocationAddress": "33 MARKET POINT DR",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "GREENVILLE",
"PracticeLocationAddressStateName": "SC",
"PracticeLocationAddressPostalCode": "29607-5768",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "864-527-0498",
"PracticeLocationAddressFaxNumber": "864-288-4608",
"EnumerationDate": "11/25/2019",
"LastUpdateDate": "09/03/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ANDERSON",
"AuthorizedOfficialFirstName": "DARIUS",
"AuthorizedOfficialMiddleName": "JEROME",
"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "864-483-0601",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "171W00000X",
"TaxonomyName": "Contractor",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"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."
}
}
}
}