Provider Demographics
NPI:1659062099
Name:CEREBROCARE OF INDIANA, LLC
Entity Type:Organization
Organization Name:CEREBROCARE OF INDIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-771-0622
Mailing Address - Street 1:34 WELLS DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-3104
Mailing Address - Country:US
Mailing Address - Phone:860-771-0622
Mailing Address - Fax:606-402-2132
Practice Address - Street 1:130 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5153
Practice Address - Country:US
Practice Address - Phone:219-588-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty