Provider Demographics
NPI:1184071086
Name:SMART BRAIN AGING INC
Entity type:Organization
Organization Name:SMART BRAIN AGING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DENBOER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:480-861-0020
Mailing Address - Street 1:275 N GATEWAY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-1700
Mailing Address - Country:US
Mailing Address - Phone:185-527-6278
Mailing Address - Fax:602-277-8146
Practice Address - Street 1:7878 N 16TH ST
Practice Address - Street 2:SUITE 250
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4449
Practice Address - Country:US
Practice Address - Phone:602-395-0715
Practice Address - Fax:602-277-8146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4026103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty