{
"Npi": {
"NPI": "1811099054",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SPACE COAST FAMILY PRACTICE",
"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": "3067 WINDLAND DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GREEN BAY",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "54311-7574",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "920-544-5868",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "3067 WINDLAND DR",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "GREEN BAY",
"PracticeLocationAddressStateName": "WI",
"PracticeLocationAddressPostalCode": "54311-7574",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "920-544-5868",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "09/01/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BETKA",
"AuthorizedOfficialFirstName": "THOMAS",
"AuthorizedOfficialMiddleName": "CHARLES",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "920-544-5868",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261Q00000X",
"TaxonomyName": "Clinic/Center",
"LicenseNumber": "ME88311",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}