{
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"EIN": null,
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"ParentOrgLBN": null,
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"NamePrefix": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "236 LATE AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BRIDGEPORT",
"MailingAddressStateName": "WV",
"MailingAddressPostalCode": "26330-1416",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "304-842-0199",
"MailingAddressFaxNumber": "304-842-1180",
"FirstLinePracticeLocationAddress": "236 LATE AVE",
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"PracticeLocationAddressCityName": "BRIDGEPORT",
"PracticeLocationAddressStateName": "WV",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "304-842-0199",
"PracticeLocationAddressFaxNumber": "304-842-1180",
"EnumerationDate": "03/14/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "COBURN",
"AuthorizedOfficialFirstName": "ROBERT",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "304-842-0199",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Home Health Agency",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}