{
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"OrgName": "SKYLINE WELLNESS CENTER",
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"NamePrefix": null,
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"FirstLineMailingAddress": "4218 KING ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ALEXANDRIA",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "22302-1507",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "703-879-5144",
"MailingAddressFaxNumber": "703-879-5860",
"FirstLinePracticeLocationAddress": "4218 KING ST",
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"PracticeLocationAddressCityName": "ALEXANDRIA",
"PracticeLocationAddressStateName": "VA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "703-879-5144",
"PracticeLocationAddressFaxNumber": "703-879-5860",
"EnumerationDate": "03/12/2009",
"LastUpdateDate": "04/14/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SANSFAUTE",
"AuthorizedOfficialFirstName": "WILFRIED",
"AuthorizedOfficialMiddleName": "F",
"AuthorizedOfficialTitle": "CHIROPRACTOR",
"AuthorizedOfficialNamePrefix": "DR.",
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"AuthorizedOfficialCredential": "D.C.",
"AuthorizedOfficialTelephoneNumber": "703-873-5144",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "111N00000X",
"TaxonomyName": "Chiropractor",
"LicenseNumber": "0104556267",
"LicenseNumberStateCode": "VA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"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."
}
}
}
}