{
"Npi": {
"NPI": "1356584932",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "BOHO PAIN MANAGEMENT AND REHABILITATION LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "3715 LINDA LN",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "RACINE",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "53405-4827",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "262-554-9465",
"MailingAddressFaxNumber": "262-554-6354",
"FirstLinePracticeLocationAddress": "3701 DURAND AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "RACINE",
"PracticeLocationAddressStateName": "WI",
"PracticeLocationAddressPostalCode": "53405-4458",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "262-497-8798",
"PracticeLocationAddressFaxNumber": "262-554-6354",
"EnumerationDate": "04/13/2009",
"LastUpdateDate": "04/15/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BOHO",
"AuthorizedOfficialFirstName": "DAVID",
"AuthorizedOfficialMiddleName": "JOHN",
"AuthorizedOfficialTitle": "PRESIDENT AND OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "O.T.R.",
"AuthorizedOfficialTelephoneNumber": "262-497-8798",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QR0400X",
"TaxonomyName": "Rehabilitation Clinic/Center",
"LicenseNumber": "919-026",
"LicenseNumberStateCode": "WI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}