Provider Demographics
NPI:1265081350
Name:BRAVO, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:BRAVO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 SE 15TH ST APT 101
Mailing Address - Street 2:
Mailing Address - City:DANIA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33004-5374
Mailing Address - Country:US
Mailing Address - Phone:786-660-0350
Mailing Address - Fax:
Practice Address - Street 1:661 SE 15TH ST APT 101
Practice Address - Street 2:
Practice Address - City:DANIA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33004-5374
Practice Address - Country:US
Practice Address - Phone:786-660-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator