MEDICARE: BRILLIANT KIDS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency
2	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1841824414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRILLIANT KIDS, LLC

Provider Business Mailing Address
First Line	:	448 NEPTUNE AVE APT 16G
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11224-4492
Country	:	US
Telephone Number	:	917-654-1010
Fax Number	:

Provider Business Practice Location Address
First Line	:	448 NEPTUNE AVE APT 16G
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11224-4492
Country	:	US
Telephone Number	:	917-654-1010
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	MRS. LARA BOGOMOLNY
Credential	:	MS ED
Telephone Number	:	917-654-1010

Provider Enumeration Date	:	02/23/2020
Last Update Date	:	02/23/2020

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