{
"Npi": {
"NPI": "1811497928",
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"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "LACA DERMATOLOGY, INC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
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"OtherNamePrefix": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1920 HILLHURST AVE #158",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "LOS ANGELES",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "90027-3352",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "818-789-6296",
"MailingAddressFaxNumber": "818-789-0374",
"FirstLinePracticeLocationAddress": "4955 VAN NUYS BLVD STE 516",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SHERMAN OAKS",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "91403-1832",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "818-789-6296",
"PracticeLocationAddressFaxNumber": "818-789-0374",
"EnumerationDate": "02/15/2018",
"LastUpdateDate": "03/25/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "VINE",
"AuthorizedOfficialFirstName": "KATHLEEN",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "MD",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "818-789-6296",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207ND0101X",
"TaxonomyName": "MOHS-Micrographic Surgery Physician",
"LicenseNumber": "C53733",
"LicenseNumberStateCode": "CA",
"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."
}
}
}
}