Healthcare Provider Details

I. General information

NPI: 1053036616
Provider Name (Legal Business Name): PLASTICITY BRAIN CENTERS OF ORLANDO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 N ALAFAYA TRL STE 600
ORLANDO FL
32826-4741
US

IV. Provider business mailing address

2000 N ALAFAYA TRL STE 600
ORLANDO FL
32826-4741
US

V. Phone/Fax

Practice location:
  • Phone: 407-955-4222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGEL POPE
Title or Position: MANAGER OF CENTER SUPPORT
Credential:
Phone: 407-955-4248