{
"Npi": {
"NPI": "1700505617",
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"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "COLLABRIA CARE",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 31001-3064",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PASADENA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "91110-3064",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "707-254-4159",
"MailingAddressFaxNumber": "707-699-1557",
"FirstLinePracticeLocationAddress": "414 S JEFFERSON ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "NAPA",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "94559-4515",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "707-254-4159",
"PracticeLocationAddressFaxNumber": "707-699-1557",
"EnumerationDate": "08/24/2022",
"LastUpdateDate": "05/14/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ANDERSON",
"AuthorizedOfficialFirstName": "DONALD",
"AuthorizedOfficialMiddleName": "W",
"AuthorizedOfficialTitle": "ASSISTANT SECRETARY OF ENROLLMENTS",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "425-358-9786",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "251T00000X",
"TaxonomyName": "PACE Provider Organization",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}