Healthcare Provider Details

I. General information

NPI: 1093280976
Provider Name (Legal Business Name): NEUROSPA BRAIN REJUVENATION CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 E COAST HWY STE 260
CORONA DEL MAR CA
92625-1932
US

IV. Provider business mailing address

2121 E COAST HWY STE 260
CORONA DEL MAR CA
92625-1932
US

V. Phone/Fax

Practice location:
  • Phone: 949-652-7301
  • Fax: 949-652-7301
Mailing address:
  • Phone: 949-652-7301
  • Fax: 949-652-7301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ALI ELAHI
Title or Position: CEO/PRESIDENT
Credential: MD
Phone: 949-705-9964