MEDICARE: TDJ ENTERPRISE, LLC (DBA BRAIN BALANCE OF CINCINNATI)

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	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1255023792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TDJ ENTERPRISE, LLC (DBA BRAIN BALANCE OF CINCINNATI)

Provider Business Mailing Address
First Line	:	12084 MONTGOMERY RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45249-1729
Country	:	US
Telephone Number	:	513-707-0125
Fax Number	:

Provider Business Practice Location Address
First Line	:	12084 MONTGOMERY RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45249-1729
Country	:	US
Telephone Number	:	513-707-0125
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHERRY MARTZ
Credential	:
Telephone Number	:	513-707-0125

Provider Enumeration Date	:	05/23/2023
Last Update Date	:	05/23/2023

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Directions to “TDJ ENTERPRISE, LLC (DBA BRAIN BALANCE OF CINCINNATI) ” Practice Location

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