{
"Npi": {
"NPI": "1497576938",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "LOLO CREEK VISION",
"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": "PO BOX 827",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "LOLO",
"MailingAddressStateName": "MT",
"MailingAddressPostalCode": "59847-0827",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "419-654-1255",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "4000 BROOKS ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MISSOULA",
"PracticeLocationAddressStateName": "MT",
"PracticeLocationAddressPostalCode": "59804-7347",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "406-251-3679",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "10/17/2024",
"LastUpdateDate": "10/17/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SMITH",
"AuthorizedOfficialFirstName": "MADISON",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OPTOMETRIST/OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "OD",
"AuthorizedOfficialTelephoneNumber": "419-654-1255",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QH0100X",
"TaxonomyName": "Health Service Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}