{
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"LastName": null,
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"FirstLineMailingAddress": "17034 173RD LN SE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "RAINIER",
"MailingAddressStateName": "WA",
"MailingAddressPostalCode": "98576-9411",
"MailingAddressCountryCode": "US",
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"FirstLinePracticeLocationAddress": "1401 GALAXY DR NE",
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"PracticeLocationAddressCityName": "LACEY",
"PracticeLocationAddressStateName": "WA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "360-456-7867",
"PracticeLocationAddressFaxNumber": "360-456-7869",
"EnumerationDate": "05/12/2014",
"LastUpdateDate": "09/30/2014",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GLANDON",
"AuthorizedOfficialFirstName": "JOSEPH",
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"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialCredential": "OD",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "152W00000X",
"TaxonomyName": "Optometrist",
"LicenseNumber": "1287",
"LicenseNumberStateCode": "WA",
"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."
}
}
}
}