Provider Demographics
NPI:1215428289
Name:BRAIN REJUVINATION CENTER OF AMERICA
Entity type:Organization
Organization Name:BRAIN REJUVINATION CENTER OF AMERICA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PAGI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-691-4816
Mailing Address - Street 1:12023 RIVERBEND DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1723
Mailing Address - Country:US
Mailing Address - Phone:810-691-4816
Mailing Address - Fax:
Practice Address - Street 1:8332 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439
Practice Address - Country:US
Practice Address - Phone:810-691-4816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Single Specialty