Provider Demographics
NPI:1700111002
Name:BRAIN INJURY RESOURCE & DEVELOPMENT CENTER, INC.
Entity Type:Organization
Organization Name:BRAIN INJURY RESOURCE & DEVELOPMENT CENTER, INC.
Other - Org Name:PHOENIX STAR CLUBHOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:540-761-5424
Mailing Address - Street 1:PO BOX 572
Mailing Address - Street 2:
Mailing Address - City:SHAWSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24162-0572
Mailing Address - Country:US
Mailing Address - Phone:540-761-5424
Mailing Address - Fax:
Practice Address - Street 1:923 14TH ST SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2001
Practice Address - Country:US
Practice Address - Phone:540-761-5424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services