MEDICARE: THE BRAIN FACTORY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	OT 00544	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OT 00544	OTHER	FL	OT LICENSE

General Provider Information

NPI Number	:	1164764049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BRAIN FACTORY LLC

Provider Business Mailing Address
First Line	:	1110 SW IVANHOE BLVD
Second Line	:	#2
City	:	ORLANDO
State	:	FL
Zip	:	32804-6305
Country	:	US
Telephone Number	:	407-375-7871
Fax Number	:

Provider Business Practice Location Address
First Line	:	7575 DR PHILLIPS BLVD STE 120
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-7221
Country	:	US
Telephone Number	:	407-375-7871
Fax Number	:	407-209-3503

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. SUSAN SHORTRIDGE
Credential	:
Telephone Number	:	407-375-7871

Provider Enumeration Date	:	03/19/2013
Last Update Date	:	03/19/2013

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Directions to “THE BRAIN FACTORY LLC ” Practice Location

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