Provider Demographics
NPI:1093209124
Name:RESTORATIVE BRAIN CLINIC, INC
Entity Type:Organization
Organization Name:RESTORATIVE BRAIN CLINIC, INC
Other - Org Name:RESTORATIVE BRAIN CLINIC, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:816-738-4430
Mailing Address - Street 1:1010 CARONDELET DR STE 112
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-4821
Mailing Address - Country:US
Mailing Address - Phone:866-695-2867
Mailing Address - Fax:816-321-1107
Practice Address - Street 1:1010 CARONDELET DR STE 112
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4821
Practice Address - Country:US
Practice Address - Phone:866-695-2867
Practice Address - Fax:816-321-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty