{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "COLLEGE AVENUE DENTAL SLEEP APPLIANCES LTD.",
"LastName": null,
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"NamePrefix": null,
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"OtherOrgName": null,
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"OtherCredential": null,
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"FirstLineMailingAddress": "505 W COLLEGE AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "JACKSONVILLE",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "62650-2405",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "217-245-5313",
"MailingAddressFaxNumber": "217-383-0204",
"FirstLinePracticeLocationAddress": "505 W COLLEGE AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "JACKSONVILLE",
"PracticeLocationAddressStateName": "IL",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "217-245-5313",
"PracticeLocationAddressFaxNumber": "217-383-0204",
"EnumerationDate": "03/24/2014",
"LastUpdateDate": "04/22/2014",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LAWSON",
"AuthorizedOfficialFirstName": "RANDALL",
"AuthorizedOfficialMiddleName": "EVERT",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "217-473-6758",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "332B00000X",
"TaxonomyName": "Durable Medical Equipment & Medical Supplies",
"LicenseNumber": "019019857",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}