Provider Demographics
NPI:1760850416
Name:HEART BRAIN INTERNATIONAL, LLC
Entity Type:Organization
Organization Name:HEART BRAIN INTERNATIONAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIMPELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBR
Authorized Official - Phone:505-933-5301
Mailing Address - Street 1:1312 SIERRA LARGA DR. NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112
Mailing Address - Country:US
Mailing Address - Phone:505-933-5301
Mailing Address - Fax:
Practice Address - Street 1:3228 LOS ARBOLES AVE NE # A-200
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1962
Practice Address - Country:US
Practice Address - Phone:505-933-5301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-11
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM102651101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12554677OtherCAQH
NM96851287Medicaid