Healthcare Provider Details

I. General information

NPI: 1619128030
Provider Name (Legal Business Name): GUADALUPE BRAVO CP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST
DETROIT MI
48201-1916
US

IV. Provider business mailing address

4646 JOHN R ST
DETROIT MI
48201-1916
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-1000
  • Fax: 313-576-1865
Mailing address:
  • Phone: 313-576-1000
  • Fax: 313-576-1865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: