{
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"IsOrgSubpart": "N",
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"OtherLastName": null,
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"FirstLineMailingAddress": "1438 STRATTFORD ST",
"SecondLineMailingAddress": null,
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"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92821-2169",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "951-339-8190",
"MailingAddressFaxNumber": "951-339-8230",
"FirstLinePracticeLocationAddress": "1572 EVERGREEN LN",
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"PracticeLocationAddressCityName": "CORONA",
"PracticeLocationAddressStateName": "CA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "562-301-8792",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/24/2025",
"LastUpdateDate": "12/15/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LE",
"AuthorizedOfficialFirstName": "CINDY",
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"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialCredential": "NP",
"AuthorizedOfficialTelephoneNumber": "562-301-8792",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "314000000X",
"TaxonomyName": "Skilled Nursing Facility",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}