{
  "npi": "1376650499",
  "enumeration_type": "NPI-2",
  "basic": {
    "authorized_official_first_name": "NED",
    "authorized_official_last_name": "DANIELS",
    "authorized_official_name_prefix": "Mr.",
    "authorized_official_name_suffix": "--",
    "authorized_official_telephone_number": "7154784824",
    "authorized_official_title_or_position": "Tribal Chairman",
    "certification_date": "2020-12-09",
    "enumeration_date": "2006-08-24",
    "last_updated": "2020-12-09",
    "organization_name": "FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER",
    "organizational_subpart": "NO",
    "status": "A"
  },
  "addresses": [
    {
      "address_1": "PO BOX 396",
      "address_2": "8201 MISH KO SWEN DRIVE",
      "address_purpose": "MAILING",
      "address_type": "DOM",
      "city": "CRANDON",
      "country_code": "US",
      "country_name": "United States",
      "fax_number": "715-478-4490",
      "postal_code": "545200396",
      "state": "WI",
      "telephone_number": "715-478-4300"
    },
    {
      "address_1": "8201 MISH KO SWEN DR",
      "address_purpose": "LOCATION",
      "address_type": "DOM",
      "city": "CRANDON",
      "country_code": "US",
      "country_name": "United States",
      "fax_number": "715-478-4490",
      "postal_code": "545208631",
      "state": "WI",
      "telephone_number": "715-478-4300"
    }
  ],
  "taxonomies": [
    {
      "code": "101YA0400X",
      "desc": "Counselor, Addiction (Substance Use Disorder)",
      "license": null,
      "primary": false,
      "state": null,
      "taxonomy_group": "193200000X - Multi-Specialty Group"
    },
    {
      "code": "261QM0850X",
      "desc": "Clinic/Center, Adult Mental Health",
      "license": null,
      "primary": false,
      "state": null,
      "taxonomy_group": ""
    },
    {
      "code": "261QM0855X",
      "desc": "Clinic/Center, Adolescent and Children Mental Health",
      "license": null,
      "primary": false,
      "state": null,
      "taxonomy_group": ""
    },
    {
      "code": "261QM0801X",
      "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
      "license": null,
      "primary": true,
      "state": null,
      "taxonomy_group": ""
    }
  ],
  "compliance": {
    "oig_leie_exclusion": {
      "excluded": false,
      "status": "CLEAR",
      "matches": [],
      "totalDbRecords": 84224
    },
    "cms_pecos_eligibility": {
      "note": "Not listed in CMS Order & Referring PECOS file or institutional NPI-2"
    }
  },
  "medicare_utilization": null,
  "enrichment": {
    "plain_english_specialty": "Licensed Outpatient Medical Clinic / Urgent Care & Ambulatory Center",
    "certifying_board": "Accreditation Association for Ambulatory Health Care (AAAHC) / CMS",
    "cms_medicare_crosswalk": [
      {
        "medicare_code": "B4[14]",
        "medicare_type": "Community Mental Health Center"
      }
    ]
  }
}