{
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"FirstLineMailingAddress": "PO BOX 411",
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"MailingAddressCityName": "EASTVALE",
"MailingAddressStateName": "CA",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "800-953-1383",
"MailingAddressFaxNumber": "800-369-3889",
"FirstLinePracticeLocationAddress": "1799 N WATERMAN AVE STE F",
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"PracticeLocationAddressCityName": "SAN BERNARDINO",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "951-347-3672",
"PracticeLocationAddressFaxNumber": "800-369-3998",
"EnumerationDate": "09/05/2017",
"LastUpdateDate": "10/20/2020",
"NPIDeactivationReasonCode": null,
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "HARVEYFULLER",
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"AuthorizedOfficialCredential": "B.A., M.A.",
"AuthorizedOfficialTelephoneNumber": "800-953-1383",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QR0405X",
"TaxonomyName": "Substance Use Disorder Rehabilitation Clinic/Center",
"LicenseNumber": "360112AN",
"LicenseNumberStateCode": "CA",
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}
},
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}
}