{
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"FirstLineMailingAddress": "1000 OLD RED TRL NW",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MANDAN",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "701-663-0012",
"MailingAddressFaxNumber": "701-663-0522",
"FirstLinePracticeLocationAddress": "1400 SKYLINE BLVD STE 1",
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"PracticeLocationAddressCityName": "BISMARCK",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "701-255-4117",
"PracticeLocationAddressFaxNumber": "701-255-4174",
"EnumerationDate": "12/18/2025",
"LastUpdateDate": "12/18/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BORSTAD",
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"AuthorizedOfficialCredential": "OD",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "152W00000X",
"TaxonomyName": "Optometrist",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}