{
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "202 E RAILROAD ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "LONG BEACH",
"MailingAddressStateName": "MS",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "228-868-2020",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "299 HIGHWAY 90",
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"PracticeLocationAddressCityName": "BAY ST LOUIS",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "228-868-2020",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "10/08/2026",
"LastUpdateDate": "10/08/2026",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CLARK",
"AuthorizedOfficialFirstName": "RICHARD",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OPTOMETRIST/OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
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"AuthorizedOfficialCredential": "OD",
"AuthorizedOfficialTelephoneNumber": "228-229-6875",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "152W00000X",
"TaxonomyName": "Optometrist",
"LicenseNumber": null,
"LicenseNumberStateCode": "NULL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}