{
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"EIN": null,
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"IsOrgSubpart": "N",
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"ParentOrgTIN": null,
"OrgName": "DFM INCORPORTATED ADOLESCENT HOME",
"LastName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "7735 S SHIELD DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FAYETTEVILLE",
"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "28314-6352",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "910-273-5473",
"MailingAddressFaxNumber": "919-498-0874",
"FirstLinePracticeLocationAddress": "3999 FAYETTEVILLE RD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "RAEFORD",
"PracticeLocationAddressStateName": "NC",
"PracticeLocationAddressPostalCode": "28376-8059",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "910-273-5473",
"PracticeLocationAddressFaxNumber": "919-498-0874",
"EnumerationDate": "04/01/2009",
"LastUpdateDate": "04/01/2009",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MONROE",
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"AuthorizedOfficialMiddleName": "DELORSE",
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"AuthorizedOfficialCredential": "BS",
"AuthorizedOfficialTelephoneNumber": "910-273-5473",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "320600000X",
"TaxonomyName": "Intellectual and/or Developmental Disabilities Residential Treatment Facility",
"LicenseNumber": "MHL-047-112",
"LicenseNumberStateCode": "NC",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}