Provider Demographics
NPI:1043928112
Name:BRAVO, VICTORIA (OWNER)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16470 N 182ND LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-6620
Mailing Address - Country:US
Mailing Address - Phone:714-501-8772
Mailing Address - Fax:
Practice Address - Street 1:4315 W EARLL DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-3819
Practice Address - Country:US
Practice Address - Phone:714-501-8772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility