{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "FAIRFAX CHIROPRACTIC AND REHAB",
"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"FirstLineMailingAddress": "10721 MAIN ST STE 104",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FAIRFAX",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "22030-6902",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "703-717-2558",
"MailingAddressFaxNumber": "703-986-1827",
"FirstLinePracticeLocationAddress": "10721 MAIN STREET SUITE#104",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "FAIRFAX",
"PracticeLocationAddressStateName": "VA",
"PracticeLocationAddressPostalCode": "22030",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "703-717-2558",
"PracticeLocationAddressFaxNumber": "703-986-1827",
"EnumerationDate": "11/22/2013",
"LastUpdateDate": "11/22/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CHOI",
"AuthorizedOfficialFirstName": "YOUNG",
"AuthorizedOfficialMiddleName": "R",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "703-599-0184",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "111N00000X",
"TaxonomyName": "Chiropractor",
"LicenseNumber": "0104556629",
"LicenseNumberStateCode": "VA",
"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."
}
}
}
}