Provider Demographics
NPI:1902204779
Name:BRAVO MD MEDICAL CENTER , INC
Entity Type:Organization
Organization Name:BRAVO MD MEDICAL CENTER , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILFREDO
Authorized Official - Middle Name:EDDY
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-409-3957
Mailing Address - Street 1:85 GRAND CANAL DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2561
Mailing Address - Country:US
Mailing Address - Phone:786-409-3957
Mailing Address - Fax:
Practice Address - Street 1:85 GRAND CANAL DR STE 101
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2561
Practice Address - Country:US
Practice Address - Phone:786-409-3957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110036261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center