Provider Demographics
NPI:1902158678
Name:BRAVO HEALTH ADVANCED CARE CENTER, P.C.
Entity Type:Organization
Organization Name:BRAVO HEALTH ADVANCED CARE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:WALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-236-6162
Mailing Address - Street 1:312 MARTIN LUTHER KING JR BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1221
Mailing Address - Country:US
Mailing Address - Phone:443-278-7001
Mailing Address - Fax:
Practice Address - Street 1:312 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1221
Practice Address - Country:US
Practice Address - Phone:443-278-7001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty