{
"Npi": {
"NPI": "1760408611",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "CHARLES S THEOFILOS MD",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
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"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "THE SPINE CENTER",
"SecondLineMailingAddress": "11621 KEW GARDENS AVE STE 101",
"MailingAddressCityName": "PALM BEACH GARDENS",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33410",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": null,
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "THE SPINE CENTER",
"SecondLinePracticeLocationAddress": "11621 KEW GARDENS AVE STE 101",
"PracticeLocationAddressCityName": "PALM BEACH GARDENS",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "33410",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "561-630-3870",
"PracticeLocationAddressFaxNumber": "561-630-3680",
"EnumerationDate": "07/14/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SHACKELFORD",
"AuthorizedOfficialFirstName": "DIRENDIA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "MANAGED CARE SPEC ALLSCRIPTS",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "800-654-0889",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "332900000X",
"TaxonomyName": "Non-Pharmacy Dispensing Site",
"LicenseNumber": "ME64328",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}