{
"Npi": {
"NPI": "1710147301",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "CUSTOM PROSTHETIC & ORTHOTIC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "801 E NORTHSIDE DR",
"SecondLineMailingAddress": "SUITE - D",
"MailingAddressCityName": "CLINTON",
"MailingAddressStateName": "MS",
"MailingAddressPostalCode": "39056-3663",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "601-906-1024",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "801 E NORTHSIDE DR",
"SecondLinePracticeLocationAddress": "SUITE - D",
"PracticeLocationAddressCityName": "CLINTON",
"PracticeLocationAddressStateName": "MS",
"PracticeLocationAddressPostalCode": "39056-3663",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "601-906-1024",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "06/17/2008",
"LastUpdateDate": "03/15/2012",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "OWENS",
"AuthorizedOfficialFirstName": "JOHNNIE",
"AuthorizedOfficialMiddleName": "MAE",
"AuthorizedOfficialTitle": "OWNER PRESIDENT",
"AuthorizedOfficialNamePrefix": "MRS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "CHILD CARE",
"AuthorizedOfficialTelephoneNumber": "601-906-1024",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "335E00000X",
"TaxonomyName": "Prosthetic/Orthotic Supplier",
"LicenseNumber": null,
"LicenseNumberStateCode": "MS",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}