{
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"OrgName": "LYNCHBURG AREA CENTER FOR INDEPENDENT LIVING",
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"NamePrefix": null,
"NameSuffix": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "500 ALLEGHANY AVE STE 520",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "LYNCHBURG",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "24501-2610",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "434-528-4971",
"MailingAddressFaxNumber": "434-528-4976",
"FirstLinePracticeLocationAddress": "500 ALLEGHANY AVE STE 520",
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"PracticeLocationAddressCityName": "LYNCHBURG",
"PracticeLocationAddressStateName": "VA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "434-528-4971",
"PracticeLocationAddressFaxNumber": "434-528-4976",
"EnumerationDate": "02/08/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "THEISEN",
"AuthorizedOfficialFirstName": "PHIL",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "EXECUTIVE DIRECTOR",
"AuthorizedOfficialNamePrefix": "MR.",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "434-528-4971",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "171M00000X",
"TaxonomyName": "Case Manager/Care Coordinator",
"LicenseNumber": null,
"LicenseNumberStateCode": "VA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}