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General NPI Number Information
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NPI Number | 1538363007
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Entity Type | Organization
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Legal Business Name | FORT WAYNE NEUROFEEDBACK, LLC
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Dates
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Enumeration Date | 06/11/2007
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Last Update Date | 05/18/2020
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Provider Practice Location Address
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Address Line | 10910 US HIGHWAY 24 W UNIT A
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City | FORT WAYNE
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State | IN
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Zip | 46814-8157
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Country | US
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Telephone | 260-432-8777
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Fax |
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Provider Business Mailing Address
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Address Line | 7127 HOMESTEAD RD STE F
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City | FORT WAYNE
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State | IN
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Zip | 46814-4601
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Country | US
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Telephone | 260-432-8777
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Fax | 260-432-8777
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Authorized Official
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Title or Position | C.A.
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Name | CELESTE M ROCKWELL
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Credential |
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Telephone | 260-432-8777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 08000637A
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License Number State | IN
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