MEDICARE: JULIUS BRAVO DPT

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	2251G0304X	Geriatric Physical Therapist	1298230	TX

General Provider Information

NPI Number	:	1720576804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIUS BRAVO DPT

Provider Business Mailing Address
First Line	:	12324 KINGS POINT DR
Second Line	:
City	:	LOVES PARK
State	:	IL
Zip	:	61111-8961
Country	:	US
Telephone Number	:	815-919-4246
Fax Number	:

Provider Business Practice Location Address
First Line	:	12324 KINGS POINT DR
Second Line	:
City	:	LOVES PARK
State	:	IL
Zip	:	61111-8961
Country	:	US
Telephone Number	:	815-919-4246
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2018
Last Update Date	:	09/13/2018

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