Provider Demographics
NPI:1356151724
Name:BRAVO WELLCARE NETWORK, LLC
Entity type:Organization
Organization Name:BRAVO WELLCARE NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVO MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:305-988-1936
Mailing Address - Street 1:7950 NW 53RD STREET
Mailing Address - Street 2:SUITE 337 #1007
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166
Mailing Address - Country:US
Mailing Address - Phone:305-988-1936
Mailing Address - Fax:
Practice Address - Street 1:7950 NW 53RD STREET
Practice Address - Street 2:SUITE 337 #1007
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166
Practice Address - Country:US
Practice Address - Phone:305-988-1936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty