{
"Npi": {
"NPI": "1750576856",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "HEATHER BETSKO, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "745 W BASELINE RD STE 21",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MESA",
"MailingAddressStateName": "AZ",
"MailingAddressPostalCode": "85210-6023",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "480-461-3937",
"MailingAddressFaxNumber": "480-461-0331",
"FirstLinePracticeLocationAddress": "777 W SOUTHERN AVE",
"SecondLinePracticeLocationAddress": "SUITE 515",
"PracticeLocationAddressCityName": "MESA",
"PracticeLocationAddressStateName": "AZ",
"PracticeLocationAddressPostalCode": "85210-5008",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "480-461-3937",
"PracticeLocationAddressFaxNumber": "480-461-0331",
"EnumerationDate": "09/11/2007",
"LastUpdateDate": "10/18/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BETSKO",
"AuthorizedOfficialFirstName": "HEATHER",
"AuthorizedOfficialMiddleName": "R",
"AuthorizedOfficialTitle": "OWNER/OPTOMETRIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "OD, FAAO",
"AuthorizedOfficialTelephoneNumber": "480-461-3937",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "152W00000X",
"TaxonomyName": "Optometrist",
"LicenseNumber": "1386",
"LicenseNumberStateCode": "AZ",
"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."
}
}
}
}