{
"Npi": {
"NPI": "1578738324",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "COASTAL WELLNESS MEDICAL GROUP, INC",
"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": "1310 LAS TABLAS RD",
"SecondLineMailingAddress": "SUITE 207",
"MailingAddressCityName": "TEMPLETON",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "93465-9737",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "805-369-1305",
"MailingAddressFaxNumber": "805-369-1309",
"FirstLinePracticeLocationAddress": "292 POSADA LN",
"SecondLinePracticeLocationAddress": "SUITE A",
"PracticeLocationAddressCityName": "TEMPLETON",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "93465-4054",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "805-434-5222",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "04/23/2008",
"LastUpdateDate": "04/28/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BRADBURN",
"AuthorizedOfficialFirstName": "CHRISTOPHER",
"AuthorizedOfficialMiddleName": "T",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.O",
"AuthorizedOfficialTelephoneNumber": "805-434-5222",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261Q00000X",
"TaxonomyName": "Clinic/Center",
"LicenseNumber": "20A7376",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}