Provider Demographics
NPI:1508541798
Name:BRAVO HEALTH MID-ATLANTIC, INC.
Entity Type:Organization
Organization Name:BRAVO HEALTH MID-ATLANTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLENA
Authorized Official - Middle Name:POWELL
Authorized Official - Last Name:PICKERING
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:512-534-7482
Mailing Address - Street 1:9623 BRAEBURN GLN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-2710
Mailing Address - Country:US
Mailing Address - Phone:512-534-7482
Mailing Address - Fax:
Practice Address - Street 1:9623 BRAEBURN GLN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78729-2710
Practice Address - Country:US
Practice Address - Phone:512-534-7482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization