{
"Npi": {
"NPI": "1932830932",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "FAMILY AFFAIR CARE GROUP MANAGEMENT, INC.",
"ParentOrgTIN": null,
"OrgName": "KEY WEST II",
"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": "1012 GREGORY ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GREENSBORO",
"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "27403-3029",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "336-274-1269",
"MailingAddressFaxNumber": "336-272-2387",
"FirstLinePracticeLocationAddress": "1722 ATHENS AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "DURHAM",
"PracticeLocationAddressStateName": "NC",
"PracticeLocationAddressPostalCode": "27707-4312",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "919-564-7543",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "06/21/2022",
"LastUpdateDate": "06/21/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GIBSON",
"AuthorizedOfficialFirstName": "WILLIE",
"AuthorizedOfficialMiddleName": "LEE",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "336-274-1269",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "315P00000X",
"TaxonomyName": "Intellectual Disabilities Intermediate Care Facility",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}