Healthcare Provider Details

I. General information

NPI: 1003431396
Provider Name (Legal Business Name): TRAUMATIC BRAIN DIAGNOSTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 WELLNESS LN
TRINITY FL
34655-5357
US

IV. Provider business mailing address

1814 WELLNESS LN
TRINITY FL
34655-5357
US

V. Phone/Fax

Practice location:
  • Phone: 813-450-8989
  • Fax:
Mailing address:
  • Phone: 813-450-8989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CAROLINE ADAMS
Title or Position: ACCOUNT ADMINISTRATOR
Credential:
Phone: 727-203-1023