Provider Demographics
NPI:1588271472
Name:BRAIN & BODY BOOST, LLC
Entity type:Organization
Organization Name:BRAIN & BODY BOOST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIM
Authorized Official - Suffix:
Authorized Official - Credentials:PT DPT
Authorized Official - Phone:708-476-1884
Mailing Address - Street 1:4360 BRISTLELEAF LN
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-1218
Mailing Address - Country:US
Mailing Address - Phone:708-476-1884
Mailing Address - Fax:
Practice Address - Street 1:4360 BRISTLELEAF LN
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-1218
Practice Address - Country:US
Practice Address - Phone:708-476-1884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-25
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty