Healthcare Provider Details

I. General information

NPI: 1922692474
Provider Name (Legal Business Name): CHILDRENS BRAIN INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 BEDFORD ST STE 14
LEXINGTON MA
02420-4640
US

IV. Provider business mailing address

3204 MAIN CAMPUS DR
LEXINGTON MA
02421-8627
US

V. Phone/Fax

Practice location:
  • Phone: 818-630-0077
  • Fax: 781-863-0005
Mailing address:
  • Phone: 617-899-5109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State

VIII. Authorized Official

Name: YAMAN EKSIOGLU
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 617-909-4142