Healthcare Provider Details

I. General information

NPI: 1063964898
Provider Name (Legal Business Name): MR. ALEJANDRO BRAVO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10929 SOUTH ST STE 208B
CERRITOS CA
90703-5368
US

IV. Provider business mailing address

10929 SOUTH ST. SUITE 208B
CERRITOS CA
90703-5340
US

V. Phone/Fax

Practice location:
  • Phone: 562-924-5526
  • Fax: 562-924-1040
Mailing address:
  • Phone: 562-924-5526
  • Fax: 562-924-1040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number1063964898
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: