Provider Demographics
NPI:1003431396
Name:TRAUMATIC BRAIN DIAGNOSTIC, LLC
Entity Type:Organization
Organization Name:TRAUMATIC BRAIN DIAGNOSTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-203-1023
Mailing Address - Street 1:1814 WELLNESS LN
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-5357
Mailing Address - Country:US
Mailing Address - Phone:813-450-8989
Mailing Address - Fax:
Practice Address - Street 1:1814 WELLNESS LN
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-5357
Practice Address - Country:US
Practice Address - Phone:813-450-8989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0301XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBrain Injury MedicineGroup - Single Specialty