{
"Npi": {
"NPI": "1770846800",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "KINGDOM CARE ASSOCIATES, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1517 CARSON CRES. EAST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PORTSMOUTH",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "23701",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "757-319-3662",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "23 CARVER CIRCLE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "PORTSMOUTH",
"PracticeLocationAddressStateName": "VA",
"PracticeLocationAddressPostalCode": "23701",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "757-319-3662",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "06/22/2012",
"LastUpdateDate": "06/22/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SCOTT",
"AuthorizedOfficialFirstName": "PATRECE",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "LLC MEMBER/OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "757-319-3662",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "302F00000X",
"TaxonomyName": "Exclusive Provider Organization",
"LicenseNumber": "302F001",
"LicenseNumberStateCode": "VA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}