Provider Demographics
NPI:1285689372
Name:BRAINCHEM CENTER LLC
Entity Type:Organization
Organization Name:BRAINCHEM CENTER LLC
Other - Org Name:BRAINCHEM LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVARISTO
Authorized Official - Middle Name:PLACEDES
Authorized Official - Last Name:BADIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-646-7733
Mailing Address - Street 1:204 LAKE HARRIS DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2632
Mailing Address - Country:US
Mailing Address - Phone:863-646-7733
Mailing Address - Fax:863-646-7733
Practice Address - Street 1:204 LAKE HARRIS DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2632
Practice Address - Country:US
Practice Address - Phone:863-646-7733
Practice Address - Fax:863-646-7733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00479392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD86060Medicare UPIN
FL56162Medicare ID - Type Unspecified