{
"Npi": {
"NPI": "1851522254",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PROVIDENCE FOOT AND ANKLE CENTER",
"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": "1417 STEIN STRAUSS ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FULLERTON",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92833-2159",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "714-797-3668",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "3130 W OLYMPIC BLVD",
"SecondLinePracticeLocationAddress": "SUITE 170",
"PracticeLocationAddressCityName": "LOS ANGELES",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "90006-2484",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "323-732-7551",
"PracticeLocationAddressFaxNumber": "323-732-7829",
"EnumerationDate": "08/03/2009",
"LastUpdateDate": "03/28/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "PARK",
"AuthorizedOfficialFirstName": "PETER",
"AuthorizedOfficialMiddleName": "SANG-WOOK",
"AuthorizedOfficialTitle": "PODIATRIST/CEO",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DPM",
"AuthorizedOfficialTelephoneNumber": "323-732-7551",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QP1100X",
"TaxonomyName": "Podiatric Clinic/Center",
"LicenseNumber": "E4031",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}