<documentationOf typeCode=“DOC”>

<serviceEvent classCode="PCPR">
  <!-- care provision -->
  <effectiveTime>
    <low nullFlavor="UNK"/>
    <high nullFlavor="UNK"/>
  </effectiveTime>
  <!-- You can include multiple performers, each with an NPI, TIN, CCN. -->
  <performer typeCode="PRF">
    <time>
      <low nullFlavor="UNK"/>
      <high nullFlavor="UNK"/>
    </time>
    {{#provider}}
    <assignedEntity>
      {{#provider_npi}}
        <id extension="{{value}}" root="2.16.840.1.113883.4.6"/>
      {{/provider_npi}}
      {{#provider_ccn}}
        <id extension="{{value}}" root="2.16.840.1.113883.4.336"/>
      {{/provider_ccn}}
      {{#specialty}}
      <code code="{{specialty}}" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
      {{/specialty}}
      {{#addresses}}
      <addr use="HP">
        <streetAddressLine>{{{provider_street}}}</streetAddressLine>
        <city>{{city}}</city>
        <state>{{state}}</state>
        <postalCode>{{zip}}</postalCode>
        <country>{{country}}</country>
      </addr>
      {{/addresses}}
      <assignedPerson>
        <name>
          <given>{{{given_name}}}</given>
          <family>{{familyName}}</family>
        </name>
      </assignedPerson>
      <representedOrganization>
        {{#provider_tin}}
        <id extension="{{value}}" root="2.16.840.1.113883.4.2"/>
        {{/provider_tin}}
        {{#addresses}}
        <addr use="HP">
          <streetAddressLine>{{{provider_street}}}</streetAddressLine>
          <city>{{city}}</city>
          <state>{{state}}</state>
          <postalCode>{{zip}}</postalCode>
          <country>{{country}}</country>
        </addr>
        {{/addresses}}
      </representedOrganization>
    </assignedEntity>
    {{/provider}}
    {{^provider}}
    <assignedEntity>
      <id extension="1982671962" root="2.16.840.1.113883.4.6"/>
      <id extension="463132" root="2.16.840.1.113883.4.336"/>
      <code code="282N00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
      <addr use="HP">
        <streetAddressLine>16432 Jayme Viaduct Manor</streetAddressLine>
        <city>Clairland</city>
        <state>MS</state>
        <postalCode>38796</postalCode>
        <country>US</country>
      </addr>
      <assignedPerson>
        <name>
          <given>Daryl</given>
          <family>Carroll</family>
        </name>
      </assignedPerson>
      <representedOrganization>
        <id extension="695939209" root="2.16.840.1.113883.4.2"/>
        <addr use="HP">
          <streetAddressLine>16432 Jayme Viaduct Manor</streetAddressLine>
          <city>Clairland</city>
          <state>MS</state>
          <postalCode>38796</postalCode>
          <country>US</country>
        </addr>
      </representedOrganization>
    </assignedEntity>
    {{/provider}}
  </performer>
</serviceEvent>

</documentationOf>