Provider Demographics
NPI:1114114873
Name:BRAVO CARE OF EAST PEORIA INC
Entity Type:Organization
Organization Name:BRAVO CARE OF EAST PEORIA INC
Other - Org Name:ROSEWOOD CARE CENTER OF EAST PEORIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEKSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-994-9070
Mailing Address - Street 1:11701 BORMAN DR STE 315
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4194
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-4928
Practice Address - Country:US
Practice Address - Phone:309-699-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1854124314000000X
IL332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid
IL=========Medicaid
IL6105810001Medicare NSC