Healthcare Provider Details

I. General information

NPI: 1396207452
Provider Name (Legal Business Name): BRUNA MARIA VANCLEAVE RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRUNA MARIA VALENTINE RPT

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 WEST WOODMEN ROAD
COLORADO SPRINGS CO
80919
US

IV. Provider business mailing address

1130 WEST WOODMEN ROAD
COLORADO SPRINGS CO
80919
US

V. Phone/Fax

Practice location:
  • Phone: 719-574-5562
  • Fax: 719-471-0445
Mailing address:
  • Phone: 719-574-5562
  • Fax: 719-471-0445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1088
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: