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General NPI Number Information
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NPI Number | 1164764049
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Entity Type | Organization
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Legal Business Name | THE BRAIN FACTORY LLC
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Dates
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Enumeration Date | 03/19/2013
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Last Update Date | 03/19/2013
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Provider Practice Location Address
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Address Line | 7575 DR PHILLIPS BLVD STE 120
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City | ORLANDO
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State | FL
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Zip | 32819-7221
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Country | US
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Telephone | 407-375-7871
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Fax | 407-209-3503
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Provider Business Mailing Address
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Address Line | 1110 SW IVANHOE BLVD #2
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City | ORLANDO
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State | FL
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Zip | 32804-6305
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Country | US
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Telephone | 407-375-7871
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. SUSAN SHORTRIDGE
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Credential |
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Telephone | 407-375-7871
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | OT 00544
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License Number State | FL
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