{
"Npi": {
"NPI": "1538534359",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "BODHI & SAGE, 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": "1525 E 53RD ST STE 808",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CHICAGO",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "60615-4583",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": null,
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1525 E 53RD ST STE 808",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CHICAGO",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "60615-4583",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "312-403-1853",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "12/04/2015",
"LastUpdateDate": "12/08/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FONG",
"AuthorizedOfficialFirstName": "ROGER",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "MEMBER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MPT, LAC",
"AuthorizedOfficialTelephoneNumber": "312-403-1853",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "171100000X",
"TaxonomyName": "Acupuncturist",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QP2000X",
"TaxonomyName": "Physical Therapy Clinic/Center",
"LicenseNumber": "070013559",
"LicenseNumberStateCode": "IL",
"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."
}
}
}
}