{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "GRAND LAKE HEALTH CARE, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "62500 E 247 LOOP",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GROVE",
"MailingAddressStateName": "OK",
"MailingAddressPostalCode": "74344-7435",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "918-787-5240",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "601 S BROADWAY ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "GROVE",
"PracticeLocationAddressStateName": "OK",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "918-801-6085",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "09/05/2018",
"LastUpdateDate": "02/25/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GELINAS",
"AuthorizedOfficialFirstName": "JOSEPH",
"AuthorizedOfficialMiddleName": "JAMES",
"AuthorizedOfficialTitle": "OWNER/PROVIDER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "NP",
"AuthorizedOfficialTelephoneNumber": "918-787-3491",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "363L00000X",
"TaxonomyName": "Nurse Practitioner",
"LicenseNumber": "80573",
"LicenseNumberStateCode": "OK",
"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."
}
}
}
}