MEDICARE: THE BRAIN AND BODY HEALTH INSTITUTE, P.A.

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	2084N0400X	Neurology Physician	P5901	TX

General Provider Information

NPI Number	:	1679979223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BRAIN AND BODY HEALTH INSTITUTE, P.A.

Provider Business Mailing Address
First Line	:	3207 R R 620 SOUTH
Second Line	:	SUITE B
City	:	LAKEWAY
State	:	TX
Zip	:	78738-6872
Country	:	US
Telephone Number	:	512-981-5801
Fax Number	:	512-857-6920

Provider Business Practice Location Address
First Line	:	3207 R R 620 SOUTH
Second Line	:	SUITE B
City	:	LAKEWAY
State	:	TX
Zip	:	78738-6872
Country	:	US
Telephone Number	:	512-981-5801
Fax Number	:	512-857-6920

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. ROBERT W VAN BOVEN
Credential	:	M.D., D.D.S.
Telephone Number	:	512-981-5801

Provider Enumeration Date	:	11/10/2014
Last Update Date	:	11/20/2014

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