=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346764750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLAIRE BRAVO, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2017
-----------------------------------------------------
Last Update Date | 11/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6310 SAN VICENTE BLVD STE 220
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-274-9988
-----------------------------------------------------
Fax | 310-274-0595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6310 SAN VICENTE BLVD STE 220
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-429-8122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CLAIRE BRAVO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 310-274-9977
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A108032
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------