Provider Demographics
NPI:1043813678
Name:BRAVO, KEVIN LEE
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:BRAVO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6377 DEL CERRO CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4710
Mailing Address - Country:US
Mailing Address - Phone:951-294-0777
Mailing Address - Fax:
Practice Address - Street 1:7130 MIRAMAR RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2353
Practice Address - Country:US
Practice Address - Phone:951-294-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer