MEDICARE: BRAINCARE, 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	293D00000X	Physiological Laboratory

General Provider Information

NPI Number	:	1891154837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAINCARE, LLC

Provider Business Mailing Address
First Line	:	2670 FIREWHEEL DR
Second Line	:	STE B
City	:	FLOWER MOUND
State	:	TX
Zip	:	75028-4601
Country	:	US
Telephone Number	:	866-848-2522
Fax Number	:	877-290-1544

Provider Business Practice Location Address
First Line	:	3200 GREENFIELD RD
Second Line	:	STE 317
City	:	DEARBORN
State	:	MI
Zip	:	48120-1802
Country	:	US
Telephone Number	:	866-848-2522
Fax Number	:	877-290-1544

Authorized Official
Title or Position	:	SR DIRECTOR OF OPERATIONS
Name	:	JANICE SHOCK
Credential	:	MBA, R.EEGT
Telephone Number	:	866-848-2522

Provider Enumeration Date	:	02/18/2016
Last Update Date	:	02/18/2016

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