{
  "enrollmentType": "855B",
  "applicationReason": "initial",
  "asOf": "2026-10-05",
  "processingWindowDays": 90,
  "provider": {
    "npi": "1555555550",
    "legalName": "Example Valley Family Medicine LLC",
    "irsLegalName": "Example Valley Family Medicine LLC",
    "taxonomyCodes": [
      "261QP2300X"
    ]
  },
  "practiceLocations": [
    {
      "name": "Example Valley Family Medicine",
      "street1": "100 Example Street",
      "street2": "Suite 2",
      "city": "Exampleton",
      "state": "OH",
      "zip": "45999-0001",
      "phone": "555-010-0100",
      "isPrimary": true
    }
  ],
  "credentials": [
    {
      "type": "license",
      "state": "OH",
      "number": "EX-000001",
      "expirationDate": "2027-06-30"
    }
  ],
  "officials": [
    {
      "role": "authorized"
    }
  ],
  "documents": [
    "licenses",
    "cp575",
    "cms588"
  ],
  "conditions": {}
}