Provider Demographics
NPI:1386195493
Name:BRAINFOREST CENTER
Entity type:Organization
Organization Name:BRAINFOREST CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:DOMENICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:888-948-1456
Mailing Address - Street 1:8660 GUION RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3011
Mailing Address - Country:US
Mailing Address - Phone:888-948-1456
Mailing Address - Fax:
Practice Address - Street 1:8660 GUION RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-3011
Practice Address - Country:US
Practice Address - Phone:888-948-1456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002663A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201209190Medicaid