{
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"FirstLineMailingAddress": "2630 WILLARD DAIRY RD",
"SecondLineMailingAddress": "SUITE B",
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"MailingAddressPostalCode": "27265-8351",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "336-884-3838",
"MailingAddressFaxNumber": "336-884-3840",
"FirstLinePracticeLocationAddress": "2630 WILLARD DAIRY RD",
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"PracticeLocationAddressCountryCode": "US",
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"PracticeLocationAddressFaxNumber": "336-884-3840",
"EnumerationDate": "12/16/2011",
"LastUpdateDate": "05/07/2018",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "PORTIS",
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"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "SITE COORDINATOR/PIC",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PHARM D",
"AuthorizedOfficialTelephoneNumber": "336-884-3837",
"Taxonomies": {
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{
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"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
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}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}