Healthcare Provider Details

I. General information

NPI: 1821339144
Provider Name (Legal Business Name): BRAIN AND SPINE INSTITUTE FOR CHILDREN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 06/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W KALEY ST SUITE 200
ORLANDO FL
32806-2939
US

IV. Provider business mailing address

25 W KALEY ST SUITE 200
ORLANDO FL
32806-2939
US

V. Phone/Fax

Practice location:
  • Phone: 407-255-2152
  • Fax: 407-264-8395
Mailing address:
  • Phone: 407-255-2152
  • Fax: 407-264-8395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KEYNE K JOHNSON
Title or Position: PRESIDENT/OWNER
Credential: M. D.
Phone: 407-378-5100