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General NPI Number Information
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NPI Number | 1003431396
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Entity Type | Organization
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Legal Business Name | TRAUMATIC BRAIN DIAGNOSTIC, LLC
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Dates
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Enumeration Date | 06/11/2020
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Last Update Date | 06/11/2020
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Provider Practice Location Address
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Address Line | 1814 WELLNESS LN
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City | TRINITY
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State | FL
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Zip | 34655-5357
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Country | US
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Telephone | 813-450-8989
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Fax |
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Provider Business Mailing Address
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Address Line | 1814 WELLNESS LN
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City | TRINITY
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State | FL
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Zip | 34655-5357
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Country | US
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Telephone | 813-450-8989
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Fax |
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Authorized Official
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Title or Position | ACCOUNT ADMINISTRATOR
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Name | MS. CAROLINE ADAMS
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Credential |
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Telephone | 727-203-1023
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0301X
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Taxonomy Name | Brain Injury Medicine (Psychiatry & Neurology) Physician
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License Number |
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License Number State |
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