{
"Npi": {
"NPI": "1346629029",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "LAKE CITY SHOE REPAIR",
"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": "3115 N GOVERNMENT WAY",
"SecondLineMailingAddress": "#7",
"MailingAddressCityName": "COEUR D ALENE",
"MailingAddressStateName": "ID",
"MailingAddressPostalCode": "83815-3790",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "208-762-0797",
"MailingAddressFaxNumber": "208-762-0791",
"FirstLinePracticeLocationAddress": "3115 N GOVERNMENT WAY",
"SecondLinePracticeLocationAddress": "#7",
"PracticeLocationAddressCityName": "COEUR D ALENE",
"PracticeLocationAddressStateName": "ID",
"PracticeLocationAddressPostalCode": "83815-3790",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "208-762-0797",
"PracticeLocationAddressFaxNumber": "208-762-0791",
"EnumerationDate": "05/27/2015",
"LastUpdateDate": "11/12/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "JOHNSON",
"AuthorizedOfficialFirstName": "WAYNE",
"AuthorizedOfficialMiddleName": "C",
"AuthorizedOfficialTitle": "SENIOR PARTNOR",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "CPED",
"AuthorizedOfficialTelephoneNumber": "208-762-0797",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "332B00000X",
"TaxonomyName": "Durable Medical Equipment & Medical Supplies",
"LicenseNumber": "NOT REQUIRED",
"LicenseNumberStateCode": "ID",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}