Basic Information
| Provider Information | |||||||||
| NPI: | 1346648789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BBRAVO, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 W BERYL AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850211606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024674733 | ||||||||
| FaxNumber: | 6023315483 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 S CRISMON RD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852093767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024674733 | ||||||||
| FaxNumber: | 6023315483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2014 | ||||||||
| LastUpdateDate: | 12/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | BRAVO | ||||||||
| AuthorizedOfficialFirstName: | BILLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6024674733 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.