{
"Npi": {
"NPI": "1497364780",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "RIO GRANDE FOOT & ANKLE SPECIALISTS LLC",
"ParentOrgTIN": null,
"OrgName": "RIO GRANDE FOOT & ANKLE SPECIALISTS LLC",
"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": "PO BOX 540610",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "N SALT LAKE",
"MailingAddressStateName": "UT",
"MailingAddressPostalCode": "84054-0610",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "801-505-0821",
"MailingAddressFaxNumber": "801-505-0803",
"FirstLinePracticeLocationAddress": "2019 GALISTEO ST STE K-2",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SANTA FE",
"PracticeLocationAddressStateName": "NM",
"PracticeLocationAddressPostalCode": "87505-2143",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "505-395-9575",
"PracticeLocationAddressFaxNumber": "877-540-1253",
"EnumerationDate": "07/23/2020",
"LastUpdateDate": "06/13/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DEITHLOFF",
"AuthorizedOfficialFirstName": "MICHELLE",
"AuthorizedOfficialMiddleName": "ELIZABETH",
"AuthorizedOfficialTitle": "DPM/OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "505-395-9575",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "213ES0103X",
"TaxonomyName": "Foot & Ankle Surgery Podiatrist",
"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."
}
}
}
}