{
"Npi": {
"NPI": "1952312324",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "CONSULTORIO OPTOMETRICO DE SG, CSP",
"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": "PO BOX 495",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SAN GERMAN",
"MailingAddressStateName": "PR",
"MailingAddressPostalCode": "00683-0495",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "787-892-1218",
"MailingAddressFaxNumber": "787-892-7480",
"FirstLinePracticeLocationAddress": "AVE. ANGEL C PEREZ #2",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SAN GERMAN",
"PracticeLocationAddressStateName": "PR",
"PracticeLocationAddressPostalCode": "00683",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "787-892-1218",
"PracticeLocationAddressFaxNumber": "787-892-7480",
"EnumerationDate": "08/11/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MORA",
"AuthorizedOfficialFirstName": "LUIS",
"AuthorizedOfficialMiddleName": "E",
"AuthorizedOfficialTitle": "OPTOMETRIST/PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "O.D.",
"AuthorizedOfficialTelephoneNumber": "787-892-1218",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "152W00000X",
"TaxonomyName": "Optometrist",
"LicenseNumber": "403-0029",
"LicenseNumberStateCode": "PR",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}