Healthcare Provider Details

I. General information

NPI: 1720712896
Provider Name (Legal Business Name): MIREYA BRAVO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 07/13/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27250 VIA INDUSTRIA STE A
TEMECULA CA
92590-3751
US

IV. Provider business mailing address

15631 LAKE TERRACE DR
LAKE ELSINORE CA
92530-5652
US

V. Phone/Fax

Practice location:
  • Phone: 858-616-6400
  • Fax:
Mailing address:
  • Phone: 951-291-3172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number88417
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: