Healthcare Provider Details

I. General information

NPI: 1649810425
Provider Name (Legal Business Name): ALAN DO VALE BRAVO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25333 BARTON RD
LOMA LINDA CA
92350
US

IV. Provider business mailing address

249A CRESCENT RD
SAN ANSELMO CA
94960-2744
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-6760
  • Fax:
Mailing address:
  • Phone: 415-497-8849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number292600
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: