Healthcare Provider Details

I. General information

NPI: 1114889060
Provider Name (Legal Business Name): PREMIER BRAIN CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 11/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

874 57TH ST UNIT 3
SACRAMENTO CA
95819-3327
US

IV. Provider business mailing address

100 CHAPEL DR STE E
MONETT MO
65708-9378
US

V. Phone/Fax

Practice location:
  • Phone: 479-276-3021
  • Fax:
Mailing address:
  • Phone: 479-276-3021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: TONY AIROSO
Title or Position: CAO
Credential:
Phone: 479-276-3021