{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "ALFORQUE TAN LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
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"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "6759 W CHARLESTON BLVD",
"SecondLineMailingAddress": "SUITE 130",
"MailingAddressCityName": "LAS VEGAS",
"MailingAddressStateName": "NV",
"MailingAddressPostalCode": "89146-2002",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "702-227-4165",
"MailingAddressFaxNumber": "702-227-7921",
"FirstLinePracticeLocationAddress": "6759 W CHARLESTON BLVD",
"SecondLinePracticeLocationAddress": "SUITE 130",
"PracticeLocationAddressCityName": "LAS VEGAS",
"PracticeLocationAddressStateName": "NV",
"PracticeLocationAddressPostalCode": "89146-2002",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "702-227-4165",
"PracticeLocationAddressFaxNumber": "702-227-7921",
"EnumerationDate": "05/23/2014",
"LastUpdateDate": "06/30/2016",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "TAN",
"AuthorizedOfficialFirstName": "RHIGEL",
"AuthorizedOfficialMiddleName": "ALFORQUE",
"AuthorizedOfficialTitle": "SOLE PROPRIETOR",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DNP APRN PMHNP",
"AuthorizedOfficialTelephoneNumber": "702-227-4165",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QM0801X",
"TaxonomyName": "Mental Health Clinic/Center (Including Community Mental Health Center)",
"LicenseNumber": "APN0007124",
"LicenseNumberStateCode": "NV",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}