{
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"OrgName": "VICTOR VALLEY ANESTHESIA MEDICAL GROUP INC",
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"FirstLineMailingAddress": "14762 KINAI RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "APPLE VALLEY",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92307-5120",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "760-242-6561",
"MailingAddressFaxNumber": "760-242-1354",
"FirstLinePracticeLocationAddress": "15248 11TH STREET",
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"PracticeLocationAddressCityName": "VICTORVILLE",
"PracticeLocationAddressStateName": "CA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "760-245-8691",
"PracticeLocationAddressFaxNumber": "760-245-8391",
"EnumerationDate": "10/31/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "THAKRAN",
"AuthorizedOfficialFirstName": "RAJENDER",
"AuthorizedOfficialMiddleName": "S",
"AuthorizedOfficialTitle": "MEDICAL DIRECTOR / PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
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"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "760-242-6561",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Specialist",
"LicenseNumber": "A55039",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}