Provider Demographics
NPI:1144454398
Name:BRAINCHILD NEUROBEHAVIORALTREATMENT CENTER LLC
Entity type:Organization
Organization Name:BRAINCHILD NEUROBEHAVIORALTREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:RALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-848-6000
Mailing Address - Street 1:9302 N MERIDIAN ST
Mailing Address - Street 2:STE 170-A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1873
Mailing Address - Country:US
Mailing Address - Phone:317-848-6000
Mailing Address - Fax:317-848-6011
Practice Address - Street 1:9302 N MERIDIAN ST
Practice Address - Street 2:STE 170-A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1873
Practice Address - Country:US
Practice Address - Phone:317-848-6000
Practice Address - Fax:317-848-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-03
Last Update Date:2009-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001899A111N00000X, 111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN08001899AOtherLICENSE