{
"Npi": {
"NPI": "1740315837",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PINEBROOK RESIDENTIAL CENTER 2",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
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"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 760",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "YADKINVILLE",
"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "27055-0760",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "336-679-8671",
"MailingAddressFaxNumber": "336-679-7500",
"FirstLinePracticeLocationAddress": "244 HARRISON AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "YADKINVILLE",
"PracticeLocationAddressStateName": "NC",
"PracticeLocationAddressPostalCode": "27055-8246",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "336-679-8671",
"PracticeLocationAddressFaxNumber": "336-679-7500",
"EnumerationDate": "02/22/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LEONARD",
"AuthorizedOfficialFirstName": "FRED",
"AuthorizedOfficialMiddleName": "H.",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MS, LPC, NC LIC. ADM",
"AuthorizedOfficialTelephoneNumber": "336-679-8671",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "311ZA0620X",
"TaxonomyName": "Adult Care Home Facility",
"LicenseNumber": "HAL-099-010",
"LicenseNumberStateCode": "NC",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}