{
"Npi": {
"NPI": "1609521558",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "BENEVOLENT HEALTHCARE SERVICES, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2212 FLOWERDEW CT",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WILLIAMSBURG",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "23185-3190",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "910-850-8636",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1769 JAMESTOWN RD STE 101",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "WILLIAMSBURG",
"PracticeLocationAddressStateName": "VA",
"PracticeLocationAddressPostalCode": "23185-2310",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "757-719-9039",
"PracticeLocationAddressFaxNumber": "866-432-1706",
"EnumerationDate": "02/18/2022",
"LastUpdateDate": "01/26/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "RIDENOUR-WOLFE",
"AuthorizedOfficialFirstName": "PEGGY",
"AuthorizedOfficialMiddleName": "JANE",
"AuthorizedOfficialTitle": "OFFICE ADMINISTRATOR",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "859-221-8587",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "171400000X",
"TaxonomyName": "Health & Wellness Coach",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207RE0101X",
"TaxonomyName": "Endocrinology, Diabetes & Metabolism Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207R00000X",
"TaxonomyName": "Internal Medicine Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"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."
}
}
}
}