Provider Demographics
NPI:1780414151
Name:BRAVO, ROMAN VALE JR
Entity type:Individual
Prefix:MR
First Name:ROMAN
Middle Name:VALE
Last Name:BRAVO
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18818 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2323
Mailing Address - Country:US
Mailing Address - Phone:760-946-2070
Mailing Address - Fax:
Practice Address - Street 1:850 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5230
Practice Address - Country:US
Practice Address - Phone:442-268-8723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X, 172V00000X
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist