{
"Npi": {
"NPI": "1881134740",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "GULFPORT WELLNESS CENTER INC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "12261 HIGHWAY 49",
"SecondLineMailingAddress": "SUITE 6",
"MailingAddressCityName": "GULFPORT",
"MailingAddressStateName": "MS",
"MailingAddressPostalCode": "39503-2975",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "228-206-0542",
"MailingAddressFaxNumber": "228-206-0550",
"FirstLinePracticeLocationAddress": "12261 HIGHWAY 49",
"SecondLinePracticeLocationAddress": "SUITE 6",
"PracticeLocationAddressCityName": "GULFPORT",
"PracticeLocationAddressStateName": "MS",
"PracticeLocationAddressPostalCode": "39503-2975",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "228-206-0542",
"PracticeLocationAddressFaxNumber": "228-206-0550",
"EnumerationDate": "02/26/2017",
"LastUpdateDate": "02/26/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SHANNON",
"AuthorizedOfficialFirstName": "MATTHEW",
"AuthorizedOfficialMiddleName": "JOSEPH",
"AuthorizedOfficialTitle": "PRESIDENT/CFO",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "501-339-6067",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261Q00000X",
"TaxonomyName": "Clinic/Center",
"LicenseNumber": "18668",
"LicenseNumberStateCode": "MS",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}