{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "BODY REGENERATION CENTER, LLC",
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"NamePrefix": null,
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"FirstLineMailingAddress": "3102 LOWE LN",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FORT WASHINGTON",
"MailingAddressStateName": "MD",
"MailingAddressPostalCode": "20744-1439",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "301-265-0886",
"MailingAddressFaxNumber": "301-265-1103",
"FirstLinePracticeLocationAddress": "801 ROEDER RD",
"SecondLinePracticeLocationAddress": "SUITE 425",
"PracticeLocationAddressCityName": "SILVER SPRING",
"PracticeLocationAddressStateName": "MD",
"PracticeLocationAddressPostalCode": "20910-4467",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "301-558-8088",
"PracticeLocationAddressFaxNumber": "301-558-8806",
"EnumerationDate": "08/23/2007",
"LastUpdateDate": "08/23/2007",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CLEMONS",
"AuthorizedOfficialFirstName": "DUANE",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CHIEF EXECUTIVE OFFICER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "CEO",
"AuthorizedOfficialTelephoneNumber": "301-841-5191",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "111N00000X",
"TaxonomyName": "Chiropractor",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"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."
}
}
}
}