Provider Demographics
NPI:1821472689
Name:VIRTUAL REALITY MEDICAL INSTITUTE
Entity Type:Organization
Organization Name:VIRTUAL REALITY MEDICAL INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WIEDERHOLD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MBA, BCB, BCN
Authorized Official - Phone:322-880-6226
Mailing Address - Street 1:30 CLOS CHAPELLE AUX CHAMPS, BOX 1.3030
Mailing Address - Street 2:
Mailing Address - City:BRUSSELS
Mailing Address - State:BELGIUM
Mailing Address - Zip Code:1200
Mailing Address - Country:BE
Mailing Address - Phone:322-880-6226
Mailing Address - Fax:
Practice Address - Street 1:30 CLOS CHAPELLE AUX CHAMPS, BOX 1.3030
Practice Address - Street 2:
Practice Address - City:BRUSSELS
Practice Address - State:BELGIUM
Practice Address - Zip Code:1200
Practice Address - Country:BE
Practice Address - Phone:322-880-6226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-11
Last Update Date:2015-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ602210779261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health