Provider Demographics
NPI:1750656245
Name:BRAIN ENHANCEMENT INSTITUTE
Entity Type:Organization
Organization Name:BRAIN ENHANCEMENT INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-797-9977
Mailing Address - Street 1:8055 W MANCHESTER AVE STE 720
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7202
Mailing Address - Country:US
Mailing Address - Phone:626-797-9977
Mailing Address - Fax:626-844-2977
Practice Address - Street 1:8055 W MANCHESTER AVE STE 720
Practice Address - Street 2:
Practice Address - City:PLAYA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90293-7202
Practice Address - Country:US
Practice Address - Phone:626-797-9977
Practice Address - Fax:626-844-2977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67163103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty