Healthcare Provider Details

I. General information

NPI: 1891230868
Provider Name (Legal Business Name): KAIZEN BRAIN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2016
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 EXECUTIVE DR SUITE 107
SAN DIEGO CA
92121-3021
US

IV. Provider business mailing address

9247 PIATTO LN
SAN DIEGO CA
92108-4767
US

V. Phone/Fax

Practice location:
  • Phone: 949-295-6693
  • Fax: 858-779-2511
Mailing address:
  • Phone: 949-295-6693
  • Fax: 858-779-2511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberA124696
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License NumberA124696
License Number StateCA

VIII. Authorized Official

Name: MOHAMMED MUZAMMIL AHMED
Title or Position: DIRECTOR
Credential: M.D.
Phone: 866-277-2659