Provider Demographics
NPI:1649810425
Name:DO VALE BRAVO, ALAN (PT)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:DO VALE BRAVO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249A CRESCENT RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2744
Mailing Address - Country:US
Mailing Address - Phone:415-497-8849
Mailing Address - Fax:
Practice Address - Street 1:25333 BARTON RD
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350
Practice Address - Country:US
Practice Address - Phone:909-558-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292600261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy