{
"Npi": {
"NPI": "1720881212",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "O2 FITNESS AND NUTRITION",
"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": "4839 W 121ST PL",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ALSIP",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "60803-2943",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "708-819-2289",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "12609 S KROLL DR",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "ALSIP",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "60803-3221",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "708-969-6110",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "03/31/2025",
"LastUpdateDate": "03/31/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "AMBROSE",
"AuthorizedOfficialFirstName": "PAOLA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER, RDN, LDN",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "BA, RDN, LDN",
"AuthorizedOfficialTelephoneNumber": "708-819-2289",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QR0400X",
"TaxonomyName": "Rehabilitation Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "302R00000X",
"TaxonomyName": "Health Maintenance Organization",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "174200000X",
"TaxonomyName": "Meals Provider",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QP3300X",
"TaxonomyName": "Pain Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QH0100X",
"TaxonomyName": "Health Service Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}