Healthcare Provider Details

I. General information

NPI: 1194912857
Provider Name (Legal Business Name): BRAVO CARE OF PEORIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W NORTHMOOR RD
PEORIA IL
61614-3435
US

IV. Provider business mailing address

11701 BORMAN DR STE 315
SAINT LOUIS MO
63146-4194
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1854122
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number StateIL

VIII. Authorized Official

Name: ALEKSANDRA SAVIC
Title or Position: AR DIRECTOR
Credential:
Phone: 314-994-9070