{
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"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"OtherCredential": null,
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"FirstLineMailingAddress": "1105 DRUID PARK AVE",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "706-737-9930",
"MailingAddressFaxNumber": "706-737-8825",
"FirstLinePracticeLocationAddress": "1105 DRUID PARK AVE",
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"PracticeLocationAddressCityName": "AUGUSTA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "706-737-9930",
"PracticeLocationAddressFaxNumber": "706-737-8825",
"EnumerationDate": "03/16/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BENJAMIN",
"AuthorizedOfficialFirstName": "JUANITA",
"AuthorizedOfficialMiddleName": "DELORES",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MBA",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Case Management Agency",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}