=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134481385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BURST OF GENIUS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2012
-----------------------------------------------------
Last Update Date | 06/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 CHAUNCEY ST APT. 3
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11233-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-495-7340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 CHAUNCEY ST APT. 3
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11233-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-495-7340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | MS. RODERICA MCCLOUD
-----------------------------------------------------
Credential | M.S. ED
-----------------------------------------------------
Telephone | 917-495-7340
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------