MEDICARE: CALIFORNIA NEUROMODULATION AND BRAIN HEALTH

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1659800357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALIFORNIA NEUROMODULATION AND BRAIN HEALTH

Provider Business Mailing Address
First Line	:	5943 FAIRVIEW PL
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-1849
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	30200 AGOURA RD STE 200
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-5433
Country	:	US
Telephone Number	:	424-744-7961
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LISBET FRANC
Credential	:
Telephone Number	:	424-744-7961

Provider Enumeration Date	:	06/06/2017
Last Update Date	:	06/06/2017

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