{
"Npi": {
"NPI": "1992103188",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "CITY OF ANGELS DERMATOLOGY INC",
"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": "4712 ADMIRALTY WAY # 665",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MARINA DEL REY",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "90292-6905",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "310-651-8240",
"MailingAddressFaxNumber": "310-651-8254",
"FirstLinePracticeLocationAddress": "435 N ROXBURY DR STE 207",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "BEVERLY HILLS",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "90210-5004",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "310-651-8240",
"PracticeLocationAddressFaxNumber": "310-651-8254",
"EnumerationDate": "12/20/2014",
"LastUpdateDate": "12/20/2014",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BILLIPS",
"AuthorizedOfficialFirstName": "MAVIS",
"AuthorizedOfficialMiddleName": "W",
"AuthorizedOfficialTitle": "DIRECTOR",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "310-651-8240",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "291U00000X",
"TaxonomyName": "Clinical Medical Laboratory",
"LicenseNumber": "CLM 000346988",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}