Provider Demographics
NPI:1871912667
Name:BRAIN RESTORATION CLINIC, PLLC
Entity type:Organization
Organization Name:BRAIN RESTORATION CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN-RONEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CORBIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-541-9117
Mailing Address - Street 1:1040 EDGEWATER CORP PKWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-4514
Mailing Address - Country:US
Mailing Address - Phone:704-541-9117
Mailing Address - Fax:704-541-9137
Practice Address - Street 1:1040 EDGEWATER CORP PKWY
Practice Address - Street 2:SUITE 106
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-4514
Practice Address - Country:US
Practice Address - Phone:704-541-9117
Practice Address - Fax:704-541-9137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-09
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006019102084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905648Medicaid
NC5905648Medicaid