{
"Npi": {
"NPI": "1730607607",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "MBA IN-HOME SERVICES, LLC",
"ParentOrgTIN": null,
"OrgName": "MBA IN-HOME SERVICES 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": "PO BOX 1386",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SIKESTON",
"MailingAddressStateName": "MO",
"MailingAddressPostalCode": "63801-1386",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "573-481-1088",
"MailingAddressFaxNumber": "573-355-5925",
"FirstLinePracticeLocationAddress": "613 DAVIS BLVD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SIKESTON",
"PracticeLocationAddressStateName": "MO",
"PracticeLocationAddressPostalCode": "63801-1958",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "573-481-1088",
"PracticeLocationAddressFaxNumber": "573-355-5925",
"EnumerationDate": "08/31/2017",
"LastUpdateDate": "07/08/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WILLIAMS",
"AuthorizedOfficialFirstName": "RHONDA",
"AuthorizedOfficialMiddleName": "L",
"AuthorizedOfficialTitle": "OWNER/DIRECTOR",
"AuthorizedOfficialNamePrefix": "MISS",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MASTER'S OF ARTS",
"AuthorizedOfficialTelephoneNumber": "573-481-1088",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "302F00000X",
"TaxonomyName": "Exclusive Provider Organization",
"LicenseNumber": "6448",
"LicenseNumberStateCode": "MO",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "253Z00000X",
"TaxonomyName": "In Home Supportive Care Agency",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}