1891868063 NPI number — BRAVO PEDIATRIC THERAPIES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891868063 NPI number — BRAVO PEDIATRIC THERAPIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAVO PEDIATRIC THERAPIES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891868063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4012 N KOLMAR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60641-1916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-551-0004
Provider Business Mailing Address Fax Number:
773-286-0493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4012 N KOLMAR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60641-1916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-551-0004
Provider Business Practice Location Address Fax Number:
773-286-0493
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRAVO
Authorized Official First Name:
CLAUDETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT SPEECH PATHOLOGIST
Authorized Official Telephone Number:
773-551-0004

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01636006 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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