{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "EASTLAKE LASER EYE ASSOCIATES",
"LastName": null,
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"Credential": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "890 EASTLAKE PARKWAY",
"SecondLineMailingAddress": "SUITE 205",
"MailingAddressCityName": "CHULA VISTA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "91914",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "619-216-0400",
"MailingAddressFaxNumber": "619-216-0440",
"FirstLinePracticeLocationAddress": "890 EASTLAKE PARKWAY",
"SecondLinePracticeLocationAddress": "SUITE 205",
"PracticeLocationAddressCityName": "CHULA VISTA",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "91914",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "619-216-0400",
"PracticeLocationAddressFaxNumber": "619-216-0440",
"EnumerationDate": "10/24/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SABLE",
"AuthorizedOfficialFirstName": "RICHARD",
"AuthorizedOfficialMiddleName": "STEVEN",
"AuthorizedOfficialTitle": "MEMBER",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "619-216-0400",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "156FX1700X",
"TaxonomyName": "Ocularist",
"LicenseNumber": "G56599",
"LicenseNumberStateCode": "CA",
"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."
}
}
}
}