Healthcare Provider Details

I. General information

NPI: 1902084536
Provider Name (Legal Business Name): CT BRAVO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 COLUMBIA ROAD BLDG. 5, SUITE B
MARTINEZ GA
30907
US

IV. Provider business mailing address

4210 COLUMBIA RD BLDG. 5, SUITE B
MARTINEZ GA
30907-0401
US

V. Phone/Fax

Practice location:
  • Phone: 706-364-3184
  • Fax: 706-364-3187
Mailing address:
  • Phone: 706-364-3184
  • Fax: 706-364-3187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License NumberHADS000775
License Number StateGA

VIII. Authorized Official

Name: MR. COLIN THOMAS RIORDAN
Title or Position: PRESIDENT
Credential: MBA,
Phone: 706-364-3184