MEDICARE: BRAVO WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QC1800X	Corporate Health Clinic/Center

General Provider Information

NPI Number	:	1548504988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAVO WELLNESS, LLC

Provider Business Mailing Address
First Line	:	20445 EMERALD PKWY STE 400
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44135-6010
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20445 EMERALD PKWY STE 400
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44135-6010
Country	:	US
Telephone Number	:	877-662-7286
Fax Number	:

Authorized Official
Title or Position	:	CEO/FOUNDER
Name	:	MR. JIM PSHOCK
Credential	:
Telephone Number	:	877-662-7286

Provider Enumeration Date	:	11/26/2012
Last Update Date	:	11/26/2012

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