{
"Npi": {
"NPI": "1518706399",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SAMS MEMORIAL COMMUNITY OUTREACH CENTER CORPORATION",
"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": "1072 MORNING GLORY LANE",
"SecondLineMailingAddress": "FACILITY",
"MailingAddressCityName": "SE DARIEN",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "31305",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "229-586-1968",
"MailingAddressFaxNumber": "800-997-4617",
"FirstLinePracticeLocationAddress": "1072 MORNING GLORY LANE",
"SecondLinePracticeLocationAddress": "FACILITY",
"PracticeLocationAddressCityName": "SE DARIEN",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "31305",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "229-586-1968",
"PracticeLocationAddressFaxNumber": "800-997-4617",
"EnumerationDate": "05/22/2024",
"LastUpdateDate": "05/22/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "REED",
"AuthorizedOfficialFirstName": "GLADYS",
"AuthorizedOfficialMiddleName": "E",
"AuthorizedOfficialTitle": "EXECUTIVE DIRECTOR/CFO",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "229-586-1968",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QM0801X",
"TaxonomyName": "Mental Health Clinic/Center (Including Community Mental Health Center)",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "251S00000X",
"TaxonomyName": "Community/Behavioral Health Agency",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}