Provider Demographics
NPI:1902208416
Name:BRAIN PERFORMANCE CENTERS, LLC
Entity Type:Organization
Organization Name:BRAIN PERFORMANCE CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:480-678-0872
Mailing Address - Street 1:3397 E VAUGHN AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4135
Mailing Address - Country:US
Mailing Address - Phone:480-678-0872
Mailing Address - Fax:
Practice Address - Street 1:6840 E BROWN RD STE 104
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-3759
Practice Address - Country:US
Practice Address - Phone:480-719-8080
Practice Address - Fax:480-981-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2478261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation