{
  "enrollmentType": "855B",
  "applicationReason": "initial",
  "asOf": "2026-10-05",
  "processingWindowDays": 90,
  "provider": {
    "npi": "1555555550",
    "legalName": "Example Valley Medicine LLC",
    "irsLegalName": "Example Valley Family Medicine, LLC",
    "taxonomyCodes": [
      "261QP2300X",
      "207Q0000X"
    ]
  },
  "practiceLocations": [
    {
      "name": "Example Valley Family Medicine",
      "street1": "PO Box 12",
      "city": "Exampleton",
      "state": "OH",
      "zip": "45999",
      "phone": "",
      "isPrimary": true
    },
    {
      "name": "Example Valley East",
      "street1": "200 Example Avenue",
      "city": "Exampleton",
      "state": "XX",
      "zip": "4599",
      "phone": "555-010-0200"
    }
  ],
  "credentials": [
    {
      "type": "license",
      "state": "OH",
      "number": "EX-000001",
      "expirationDate": "2026-11-15"
    },
    {
      "type": "liability_insurance",
      "expirationDate": "2026-09-30"
    }
  ],
  "officials": [
    {
      "role": "delegated"
    }
  ],
  "documents": [
    "licenses",
    "cms588"
  ],
  "conditions": {}
}