Healthcare Provider Details

I. General information

NPI: 1942057989
Provider Name (Legal Business Name): BRAIN DYNAMICS INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 SPENCER ST STE 102B
LAS VEGAS NV
89119-3924
US

IV. Provider business mailing address

6565 SPENCER ST STE 102B
LAS VEGAS NV
89119-3924
US

V. Phone/Fax

Practice location:
  • Phone: 702-267-8295
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE LUNA
Title or Position: OWNER
Credential:
Phone: 702-267-8295