Provider Demographics
NPI:1548552300
Name:BRAVO, ALEXANDER JAMES (DPT)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JAMES
Last Name:BRAVO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 JENNIFER DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4983
Mailing Address - Country:US
Mailing Address - Phone:801-941-2137
Mailing Address - Fax:
Practice Address - Street 1:955 CHAMBERS ST
Practice Address - Street 2:SUITE G1
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4595
Practice Address - Country:US
Practice Address - Phone:801-941-2137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7963402-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist