{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "VILLAGE SHOE SERVICE, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
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"OtherLastName": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "4286 RAILROAD AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "TUCKER",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30084-4487",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "770-938-7463",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "4286 RAILROAD AVE",
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"PracticeLocationAddressCityName": "TUCKER",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "770-938-7463",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "12/03/2008",
"LastUpdateDate": "09/25/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SCHUPBACH",
"AuthorizedOfficialFirstName": "LARRY",
"AuthorizedOfficialMiddleName": "WILLIAM",
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"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": "C.PED.",
"AuthorizedOfficialTelephoneNumber": "770-938-7463",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Prosthetic/Orthotic Supplier",
"LicenseNumber": "CPED2232",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}