{
"Npi": {
"NPI": "1710438338",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "INTERNATIONAL RECOVERY CENTER, LLC",
"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": "1825 NW 112TH AVE",
"SecondLineMailingAddress": "SUITE 151",
"MailingAddressCityName": "MIAMI",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33172-1815",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "305-600-3255",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1825 NW 112TH AVE",
"SecondLinePracticeLocationAddress": "SUITE 151",
"PracticeLocationAddressCityName": "MIAMI",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "33172-1815",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "305-600-3255",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "10/19/2016",
"LastUpdateDate": "07/21/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KORNMILLER",
"AuthorizedOfficialFirstName": "KELI",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CLIENT ONBOARDING SUPERVISOR",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "561-672-8345",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QR0800X",
"TaxonomyName": "Recovery Care Clinic/Center",
"LicenseNumber": "1301",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}