{
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"FirstLineMailingAddress": "3904 WHITE BEAR AVE N",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WHITE BEAR LAKE",
"MailingAddressStateName": "MN",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "320-309-2403",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "440 BUNKER LAKE BLVD NW STE 105",
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"PracticeLocationAddressCityName": "ANOKA",
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"PracticeLocationAddressTelephoneNumber": "763-330-0393",
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"EnumerationDate": "02/27/2025",
"LastUpdateDate": "05/01/2025",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KUSS",
"AuthorizedOfficialFirstName": "SAMUEL",
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"AuthorizedOfficialCredential": "DC",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "111N00000X",
"TaxonomyName": "Chiropractor",
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"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."
}
}
}
}