Provider Demographics
NPI:1851804785
Name:OPTIMAL BODY BRAIN, LLC
Entity Type:Organization
Organization Name:OPTIMAL BODY BRAIN, LLC
Other - Org Name:ADVANCED NEUROFEEDBACK CENTER, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:214-484-1313
Mailing Address - Street 1:12820 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-1526
Mailing Address - Country:US
Mailing Address - Phone:214-484-1313
Mailing Address - Fax:
Practice Address - Street 1:12820 HILLCREST RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-1526
Practice Address - Country:US
Practice Address - Phone:214-484-1313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8803261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1659488047OtherNPI