Provider Demographics
NPI:1700380904
Name:THE BRAIN SPA, LLC
Entity Type:Organization
Organization Name:THE BRAIN SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:803-605-4806
Mailing Address - Street 1:5200 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2374
Mailing Address - Country:US
Mailing Address - Phone:803-605-4806
Mailing Address - Fax:803-764-4880
Practice Address - Street 1:5200 EAST AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2374
Practice Address - Country:US
Practice Address - Phone:803-605-4806
Practice Address - Fax:803-764-4880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME119718OtherMEDICAL LICENSE NUMBER