Basic Information
| Provider Information | |||||||||
| NPI: | 1891230868 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAIZEN BRAIN CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORY CONCUSSION CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9247 PIATTO LN | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921084767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492956693 | ||||||||
| FaxNumber: | 8587792511 | ||||||||
| Practice Location | |||||||||
| Address1: | 4510 EXECUTIVE DR | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921213021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492956693 | ||||||||
| FaxNumber: | 8587792511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2016 | ||||||||
| LastUpdateDate: | 12/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | AHMED | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMED | ||||||||
| AuthorizedOfficialMiddleName: | MUZAMMIL | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8662772659 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084B0040X | A124696 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Behavioral Neurology & Neuropsychiatry | 2084P0301X | A124696 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP |
No ID Information.