{
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "WELLENDORF ENT, P.C.",
"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 766",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CARROLL",
"MailingAddressStateName": "IA",
"MailingAddressPostalCode": "51401-0766",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "712-792-4368",
"MailingAddressFaxNumber": "712-792-4351",
"FirstLinePracticeLocationAddress": "405 S CLARK ST",
"SecondLinePracticeLocationAddress": "SUITE 215",
"PracticeLocationAddressCityName": "CARROLL",
"PracticeLocationAddressStateName": "IA",
"PracticeLocationAddressPostalCode": "51401-3065",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "712-792-4368",
"PracticeLocationAddressFaxNumber": "712-792-2056",
"EnumerationDate": "05/10/2007",
"LastUpdateDate": "03/26/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WELLENDORF",
"AuthorizedOfficialFirstName": "TRACEY",
"AuthorizedOfficialMiddleName": "G",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
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"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "712-792-4368",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207Y00000X",
"TaxonomyName": "Otolaryngology Physician",
"LicenseNumber": "30594",
"LicenseNumberStateCode": "IA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
}
}
}
}