{
"Npi": {
"NPI": "1962775817",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "WESTSIDE OPTICAL SHOP,LLC",
"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": "1413 JOHN B WHITE SR BLVD",
"SecondLineMailingAddress": "SUITE A",
"MailingAddressCityName": "SPARTANBURG",
"MailingAddressStateName": "SC",
"MailingAddressPostalCode": "29306-3995",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "864-587-1039",
"MailingAddressFaxNumber": "864-587-1936",
"FirstLinePracticeLocationAddress": "1413 JOHN B WHITE SR BLVD",
"SecondLinePracticeLocationAddress": "SUITE A",
"PracticeLocationAddressCityName": "SPARTANBURG",
"PracticeLocationAddressStateName": "SC",
"PracticeLocationAddressPostalCode": "29306-3995",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "864-587-1039",
"PracticeLocationAddressFaxNumber": "864-587-1936",
"EnumerationDate": "02/22/2012",
"LastUpdateDate": "05/31/2012",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ROEL",
"AuthorizedOfficialFirstName": "LAWRENCE",
"AuthorizedOfficialMiddleName": "EDMUND",
"AuthorizedOfficialTitle": "OWNER/PROVIDER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "864-542-1308",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "332H00000X",
"TaxonomyName": "Eyewear Supplier",
"LicenseNumber": "120021119",
"LicenseNumberStateCode": "SC",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}