Basic Information
| Provider Information | |||||||||
| NPI: | 1184071086 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SMART BRAIN AGING INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 N GATEWAY DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850341700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1855276278 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Practice Location | |||||||||
| Address1: | 7878 N 16TH ST | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850204449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023950715 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2016 | ||||||||
| LastUpdateDate: | 05/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | DENBOER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4808610020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 4026 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.