{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PACIFIC COAST CLINIC SALEM LLC",
"LastName": null,
"FirstName": null,
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"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1249 FAIRVIEW AVE SE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SALEM",
"MailingAddressStateName": "OR",
"MailingAddressPostalCode": "97302-2534",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "971-239-1146",
"MailingAddressFaxNumber": "503-907-9933",
"FirstLinePracticeLocationAddress": "1249 FAIRVIEW AVE SE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SALEM",
"PracticeLocationAddressStateName": "OR",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "971-239-1146",
"PracticeLocationAddressFaxNumber": "503-907-9933",
"EnumerationDate": "02/11/2010",
"LastUpdateDate": "06/01/2011",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KHALEEQ",
"AuthorizedOfficialFirstName": "ERUM",
"AuthorizedOfficialMiddleName": "AYAZ",
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"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "971-239-1146",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QM0850X",
"TaxonomyName": "Adult Mental Health Clinic/Center",
"LicenseNumber": "MD24295",
"LicenseNumberStateCode": "OR",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}