{
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"EIN": null,
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"IsOrgSubpart": "N",
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"LastName": null,
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"NameSuffix": null,
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"FirstLineMailingAddress": "2655 CLEVELAND AVE STE A",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SANTA ROSA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "95403-2779",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "707-542-8883",
"MailingAddressFaxNumber": "707-546-7787",
"FirstLinePracticeLocationAddress": "2655 CLEVELAND AVE STE A",
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"PracticeLocationAddressCityName": "SANTA ROSA",
"PracticeLocationAddressStateName": "CA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "707-542-8883",
"PracticeLocationAddressFaxNumber": "707-546-7787",
"EnumerationDate": "08/11/2017",
"LastUpdateDate": "09/25/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WU",
"AuthorizedOfficialFirstName": "ERICA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CEO",
"AuthorizedOfficialNamePrefix": "DR.",
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"AuthorizedOfficialCredential": "O.D.",
"AuthorizedOfficialTelephoneNumber": "530-902-0271",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Optometrist",
"LicenseNumber": "14545",
"LicenseNumberStateCode": "CA",
"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."
}
}
}
}