=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114889060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER BRAIN CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2025
-----------------------------------------------------
Last Update Date | 12/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 874 57TH ST UNIT 3
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-276-3021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 CHAPEL DR STE E
-----------------------------------------------------
City | MONETT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65708-9378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-276-3021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CAO
-----------------------------------------------------
Name | TONY AIROSO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-276-3021
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------