Provider Demographics
NPI:1164764049
Name:THE BRAIN FACTORY LLC
Entity Type:Organization
Organization Name:THE BRAIN FACTORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORTRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-375-7871
Mailing Address - Street 1:1110 SW IVANHOE BLVD
Mailing Address - Street 2:#2
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6305
Mailing Address - Country:US
Mailing Address - Phone:407-375-7871
Mailing Address - Fax:
Practice Address - Street 1:7575 DR PHILLIPS BLVD STE 120
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7221
Practice Address - Country:US
Practice Address - Phone:407-375-7871
Practice Address - Fax:407-209-3503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 00544261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT 00544OtherOT LICENSE