Provider Demographics
NPI:1558418251
Name:BRAVO, GUILLERMO W (DC)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:W
Last Name:BRAVO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:BILL
Other - Middle Name:
Other - Last Name:BRAVO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:229 N CENTRAL AVE #501
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-3534
Mailing Address - Country:US
Mailing Address - Phone:818-242-1092
Mailing Address - Fax:
Practice Address - Street 1:229 N CENTRAL AVE STE 501
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-3534
Practice Address - Country:US
Practice Address - Phone:818-242-1092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24294111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor